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Comprehensive Handbook of

Laboratory &
Diagnostic Tests

Anne M. Van Leeuwen


Mickey Lynn Bladh

/
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Anne M. Van Leeuwen
Mickey Lynn Bladh

F. A. DAVIS COMPANY Philadelphia

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F. A. Davis Company
1915 Arch Street
Philadelphia
PA19103

www.fadavis.com

Copyright 2015 by F. A. Davis Company

Copyright 2009, 2006, 2003, 2011, 2013 by F.A. Davis Company.All rights reserved.This
book is protected by copyright. No part of it may be reproduced, stored in a retrieval
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Printed in the United States of America

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Publisher: Lisa B. Houck


Art and Design Manager: Carolyn OBrien
Content Project Manager II: Victoria White
Digital Publishing Project Manager: Sandra Glennie

As new scientific information becomes available through basic and clinical research, rec-
ommended treatments and drug therapies undergo changes. The authors and publisher
have done everything possible to make this book accurate, up to date, and in accord with
accepted standards at the time of publication. The authors, editors, and publisher are not
responsible for errors or omissions or for consequences from application of the book,
and make no warranty, expressed or implied, in regard to the contents of the book. Any
practice described in this book should be applied by the reader in accordance with profes-
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changes and new information regarding dose and contraindications before administering
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Proudly sourced and uploaded by [StormRG]
Van Leeuwen, Anne M., author. Kickass Torrents | TPB | ET | h33t
Daviss comprehensive handbook of laboratory diagnostic tests with nursing implications/
Anne M. Van Leeuwen, Mickey Lynn Bladh.6th edition.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-8036-4405-2 -- ISBN 0-8036-4405-1
I. Bladh, Mickey Lynn, author. II.Title.
[DNLM: 1.Clinical Laboratory TechniquesHandbooks. 2.Clinical Laboratory
TechniquesNurses Instruction. 3.Nursing DiagnosismethodsHandbooks.
4. Nursing DiagnosismethodsNurses Instruction. QY 39]

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Dedication

Inspiration springs from Passion. Passion is born from unconstrained love,


commitment, and a vision no one else can own.
Lyndamy best friend and extraordinarily gifted nursethank you, I could
not have done this without your love, strong support, and belief in me. My
gratitude to Mom, Dad, Adele, Gram . . . all my family and friends, for I am truly
blessed by your humor and faith. A huge hug for my daughters, Sarah and
MargaretI love you very much. To my puppies, Maggie, Taylor, and Emma, for
their endless and unconditional love. Many thanks to my friend and
wonderful coauthor Mickey; to all the folks at F.A. Davis, especially Rob and
Victoria for their guidance, support, and great ideas. And, very special thanks
to Lisa Houck, publisher, for her friendship, excellent direction, and
unwavering encouragement.

Anne M. Van Leeuwen, MA, BS, MT (ASCP)


Medical Laboratory Scientist & Independent Author
Greater Seattle Area, Washington

An eternity of searching would never have provided me with a man more


loving and supportive than my husband, Eric. He is the sunshine in my soul,
and I will be forever grateful for the blessing of his presence in my life. I am
grateful to my five children, Eric, Anni, Phillip, Mari, and Melissa, for the
privilege of being their mom; always remember that you are limited only by
your imagination and willingness to try. To Anne, thanks so much for the
opportunity to spread my wings, for your patience and guidance, and thanks
to Lynda for the miracle of finding me. To all of those at F.A. DavisRob,
Victoria, and Lisayou are the best. Lastly, to my beloved parents, thanks with
hugs and kisses.

Mickey L. Bladh, RN, MSN


Coordinator, Nursing Education
PIH Health Hospital
Whittier, California

We are so grateful to all the people who have helped us make this book
possible. We thank our readers for allowing us this important opportunity to
touch their lives. We are also thankful for our association with the F.A. Davis
Company. We value and appreciate the efforts of all the people associated
with F.A. Davis because without their hard work this publication could not
succeed. We recognize all the wonderful people in leadership, the editors,
freelance consultants, designers, IT gurus, and digital applications developers,
as well as those in sales & marketing, distribution, and finance. We have a
deep appreciation for the Davis Educational Consultants. They are tasked
with being our voice. Their exceptional ability to communicate is what
actually brings our book to the market. We would like to give special

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vi Dedication

acknowledgement to the outstanding publishing professionals who were our


core support team throughout the development of this edition:

Lisa Houck
Publisher

Robert Allen
Content Applications Developer

Victoria White
Content Project Manager II

Cynthia Naughton
Production Manager, Digital Solutions

Sandra Glennie
Project Manager, Digital Solutions

Carolyn OBrien
Art & Design Manager

Jaclyn Lux
Marketing Manager

Dan Clipner
Production Manager

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About This Book

This book is a reference for nurses, nursing students, and other health-care pro-
fessionals. It is useful as a clinical tool as well as a supportive text to supplement
clinical courses. It guides the nurse in planning what needs to be assessed,
monitored, treated, and taught regarding pretest requirements, intratest proce-
dures, and post-test care. It can be used by nursing students at all levels as a
textbook in theory classes, integrating laboratory and diagnostic data as one
aspect of nursing care; by practicing nurses to update information; and in clinical
settings as a quick reference. Designed for use in academic and clinical settings,
Daviss Comprehensive Handbook of Laboratory and Diagnostic TestsWith
Nursing Implications provides a comprehensive reference that allows easy
access to information about laboratory and diagnostic tests and procedures.

WHATS NEW IN THE 6th EDITION?


Two new monographs:
Genetic Testing
Bioterrorism and Public Health Safety Concerns: Testing for Toxins and
Infectious Agents
New or updated information for more than 50 different tests including
further discussion of:
Molecular testing and companion diagnostics
Pediatric and geriatric considerations
Specific contraindications and corresponding rationales
Specific nursing problems, associated patient signs and symptoms, and poten-
tial nursing interactions
Specific complications with corresponding rationales and potential
interventions
Patient education, including references to Websites for information related to
specific health conditions or disease management guidelines
Expected patient outcomes expressed in terms of understanding, ability,
and response. The expected patient outcomes are expressed in statements
that reflect the patients understanding of their medical situation and what it
will take to achieve the most positive outcome possible; their demonstrated
ability to apply instructions, explanations, and education toward a goal; and
their response to various aspects of Safe and Effective Nursing Care used in
their situation
Material regarding genetic markers for Alzheimers disease; tests used to diagnose
gluten-sensitive enteropathies; immunosuppressant therapies used for organ trans-
plant patients; genetic testing for drug resistance; description of the arterial
brachial index; tests used to evaluate intermediate glycemic control; the use of
pharmacogenetics to help explain why some patients dont respond as expected
to their medications; and the use of home test kits added in previous editions
Evidence-based practice is reflected throughout in:
Suggestions for patient teaching that reflect changes in standards of care,
particularly with respect to current guidelines for cancer screening
The most current Centers for Disease Control and Prevention (CDC) guide-
lines for communicable diseases such as syphilis, tuberculosis, and HIV
vii

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viii About This Book

The most current guidelines for the prevention of cardiovascular disease


(CVD) developed by the American College of Cardiology (ACA) and the
American Heart Association (AHA) in conjunction with members of the
National Heart, Lung, and Blood Institutes (NHLBI) ATP IV Expert Panel

Critical Findings sections now include:


A sample statement that walks the nurse through the process for timely noti-
fication and documentation of critical values
Conventional and SI units
Commonly reported pediatric and neonatal values
The Reference Value heading in the laboratory monographs is now called
Normal Findings to (a) use terminology that is easier to recognize and interpret
and (b) use consistent terminology in laboratory and diagnostic monographs.
Weve included related information within the following monographs for
this edition:
Nasal cytology in Allergen-Specific Immunoglobulin E
Digital subtraction in all the angiography monographs
Post void residual in Cystometry
Xenon enhanced CT in Computed Tomography, Brain
Magnetic resonance cholangiopancreatography in Magnetic Resonance
Imaging, Abdomen
Bladder scan in Ultrasound, Bladder
Digital rectal examination (DRE) in Ultrasound, Prostate
Some monographs have been combined to consolidate similar tests, and a
few less frequently used tests have been condensed into a mini-monograph for-
mat that highlights abbreviated test-specific facts, with the full monographs for
those tests now resident on the DavisPlus Web site (http://davisplus.fadavis.com).
The System Tables at the back of the book now indicate the individual stud-
ies that contain information regarding genetic testing so the information, also
in the index, can be located quickly.

New: The Intersection of Nursing Care and Lab/Dx Testing

We hear every day from students and instructors that they want a laboratory and
diagnostic test reference that will help them connect-the-dotsthat will show
them how to integrate laboratory and diagnostic test results into safe, compassion-
ate, comprehensive, and effective nursing care. So we have revised the 6th edition
of the Handbook to be not only the comprehensive reference it was originally
designed to be, but it now also presents carefully selected studies that have been
enhanced to reflect aspects of Safe and Effective Nursing Care. The enhanced
studies allow the reader to drill down further into the nursing implications. More
than 80 studies have been expanded and examples include:
Bilirubin
Blood Gases
Blood Groups and Antibodies
Cerebrospinal Fluid Analysis
Chlamydia Group Antibody
Chloride, Sweat
Complete Blood Count, Hemoglobin; Platelet Count; and WBC Count

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About This Book ix

D-Dimer
Glucose
Glucose Tolerance Tests
Newborn Screening
Prostate Specific Antigen
Prothrombin Time and INR
Rheumatoid Factor
Thyroid Stimulating Hormone
Tuberculosis Testing

WHATS NEW ONLINE?


Davisplus
The following additional information is available at the DavisPlus web site
(http://davisplus.fadavis.com):
Case studies in both instructor and student versions formatted to help the
novice learn how to clinically reason by using the nursing process to problem
solve. Cases are purposefully designed to promote discussion of situations
that may occur in the clinical setting. Situations may be medical, ethical,
family-related, patient-related, nurse-related,or any combination.
Common potential nursing diagnoses associated with laboratory and diagnostic
testing.
Age-specific nursing care guidelines with suggested approaches to persons at
various developmental stages to assist the provider in facilitating cooperation
and understanding.
Transfusion reactions, their signs and symptoms, associated laboratory find-
ings, and potential nursing interventions.
Introduction to CLIA (Clinical Laboratory Improvement Amendments) with
an explanation of the different levels of testing complexity.
Herbs and nutraceuticals associated with adverse clinical reactions or drug
interactions related to the affected body system.
Standard precautions.
Interactive drag-and-drop, quiz-show, flash card, and multiple-choice exercises.
A printable file of critical findings for laboratory and diagnostic tests.

Instructor Guide and Student Guide


Organized by nursing curriculum, presentations, and case studies with
emphasis on laboratory and diagnostic test-related information and nursing
implications have been developed for selected conditions and body systems,
including sensory, obstetric, and nutrition coverage.
Open-ended and NCLEX-type multiple-choice questions as well as suggested
critical-thinking activities are provided.
Updated with broadened age-related categories designed to enhance clinical
communication. Each case study includes at least one test that appears in the
6e Handbook as an enhanced monograph. Information in the enhanced mono-
graph can be referenced in the Handbook for the material that contains detailed
nursing problems, complications, patient education, and expected patient
outcomes for additional Safe and Effective Nursing Care teaching moments.
PowerPoint presentation of laboratory and diagnostic pretest, intratest, and
post-test concepts integrated with nursing process.

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x About This Book

Monograph Library
A searchable library of mini-monographs for all the active tests included in
the text. The mini-monograph gives each tests full name, synonyms and
acronyms, specimen type (laboratory tests) or area of application (diagnostic
tests), reference ranges or contrast, and results.
An archive of full monographs of retired tests that are referenced by mini-
monographs in the text.

WHAT WE KEPT FROM PREVIOUS EDITIONS


System Tables
Alphabetical listings of laboratory and diagnostic tests organized by related
body systems. The tables have been revised to quickly identify individual tests
in each table that contain information regarding genetic testing.

Alphabetical Order
The tests and procedures are presented in this book in alphabetical order by
their complete name, allowing the user to locate information quickly without
having to first place tests in a specific category or body system. Wherever pos-
sible, information within the Indications, Potential Diagnosis, and Interfering
Factors (drug lists) sections also has been organized alphabetically.

Consistent Format
The following information is provided for each laboratory and diagnostic tests:
Each monograph is titled by the test name and given in its commonly used
designation.
Synonyms and Acronyms for each test are listed where appropriate.
The Common Use section includes a brief description of the purpose for
the study.
The Specimen section includes the type of specimen usually collected and,
where appropriate, the type of collection tube or container commonly rec-
ommended. The amount of specimen collected for blood studies reflects the
amount of serum, plasma, or whole blood required to perform the test and
thus provides a way to project the total number of specimen containers
required because patients usually have multiple laboratory tests requested for
a single draw. Specimen requirements vary by laboratory. The amount of
specimen collected is usually more than what is minimally required so that
additional specimen is available, if needed, for repeat testing (quality-control
failure, dilutions, or confirmation of unexpected results). In the case of diag-
nostic tests, the type of procedure (e.g., nuclear medicine, x-ray) is given.
Normal Findings for each monograph include age-specific, gender-specific,
and ethnicity-specific variations, when indicated. It is important to consider
the normal variation of laboratory values over the life span and across cul-
tures; sometimes what might be considered an abnormal value in one circum-
stance is actually what is expected in another. Normal findings for laboratory
tests are given in conventional and standard international (SI) units.The factor
used to convert conventional to SI units is also given. Because laboratory
values can vary by method, each laboratory reference range is listed along
with the associated methodology.
The Description section includes the studys purpose and insight into how
and why the test results can affect health. Some test descriptions also provide

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About This Book xi

insight into how test results influence the development of national health
guidelines.
A separate Contraindications section has been created to differentiate cir-
cumstances that might put the patient at risk if the procedure is performed
from interfering factors that may indirectly affect patient care by adversely
affecting the results of the study.
Indications are a list of what the test is used for in terms of assessment,
evaluation, monitoring, screening, identifying, or assisting in the diagnosis of
a clinical condition.
The Potential Diagnosis section presents a list of conditions in which values
may be increased or decreased and, in some cases, an explanation of varia-
tions that may be encountered.
Critical Findings that may be life threatening or for which particular concern
may be indicated are given in conventional and SI units, along with age span
considerations where applicable. This section also includes signs and symp-
toms associated with a critical value as well as possible nursing interventions
and the nurses role in communication of critical findings to the appropriate
health-care provider.
Interfering Factors are substances or circumstances that may influence the
results of the test, rendering the results invalid or unreliable. Knowledge of
interfering factors is an important aspect of quality assurance and includes
pharmaceuticals, foods, natural and additive therapies, timing of test in rela-
tion to other tests or procedures, collection site, handling of specimen, and
underlying patient conditions.
The Pretest section addresses the need to:
Positively identify the patient using at least two unique identifiers before
providing care, treatment, or services.
Provide an explanation to the patient, in the simplest terms possible, of the
purpose of the study.
Obtain pertinent clinical, laboratory, dietary, and therapeutic history of the
patient, especially as it pertains to comparison of previous test results,
preparation for the test, and identification of potentially interfering factors.
Explain the requirements and restrictions related to the procedure as well
as what to expect; provide the education necessary for the patient to be
properly informed.
Anticipate and allay patient and family concerns or anxieties with consider-
ation of social and cultural issues during interactions.
Provide for patient safety.
Some monographs have an additional section for Nursing Problems at the
beginning of the pretest section.The enhanced information presents problems
the nurse might encounter relative to the study topic (e.g., glucose), signs and
symptoms associated with abnormal study findings, and possible interventions.
The additional information provides the reader with the opportunity to drill
further down into the nursing implications. It is provided with the thought that
incorporating laboratory and diagnostic data, on a day-to-day basis, by using the
nursing process can be taught and reinforced using simple examples.
The Intratest section can be used in a quality-control assessment or as a guide
to the nurse who may be called on to participate in specimen collection or
perform preparatory procedures. It provides:
Specific directions for specimen collection and test performance

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xii About This Book

Important information such as patient sensation and expected duration of


the procedure
Precautions to be taken by the nurse and patient
Some monographs have an additional section for study specific complica-
tions and rationales in the Intratest section. The additional information is
another opportunity to drill further down into the nursing implications. It is
provided as a reminder to anticipate the potential for procedural complications
and be prepared to identify them across the age continuum.
The Post-Test section provides guidelines regarding:
Specific monitoring and therapeutic measures that should be performed
after the procedure (e.g., maintaining bedrest, obtaining vital signs to com-
pare with baseline values, signs and symptoms of complications)
Specific instructions for the patient and family, such as when to resume
usual diet, medications, and activity
General nutritional guidelines related to excess or deficit as well as common
food sources for dietary replacement
Indications for interventions from public health representatives or for spe-
cial counseling related to test outcomes
Indications for follow-up testing that may be required within specific time
frames
An alphabetical listing of related laboratory and/or diagnostic tests that is
intended to provoke a deeper and broader investigation of multiple pieces
of information; the tests provide data that, when combined, can form a more
complete picture of health or illness
Reference to the specific body system tables of related laboratory and diag-
nostic tests that might bear on a patients situation
Some monographs have an additional section for specific patient education
and expected patient outcomes in the post-test section. The additional informa-
tion is another opportunity to drill further down into the nursing implications.
It is provided as a reminder of the nurses role as educator and advocate.

Color and Icons


Design is used to facilitate locating critical information at a glance. On the
inside front and back covers is a full-color chart describing tube tops used for
various blood tests and their recommended order of draw.

Nursing Process
Within each phase of the testing procedure, we describe the nurses roles and
responsibilities as defined by the nursing process.

Appendices
These include:
A summary of guidelines for patient preparation with specimen collection
procedures and materials which has been revised to reflect considerations
for special patient populations.
A listing of critical findings for laboratory studies.
A listing of critical findings for diagnostic studies.

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About This Book xiii

Index
Completely updated to reflect the addition of new tests, conditions, and other
key words.

Assumptions
The authors recognize that preferences for the use of specific medical termi-
nology may vary by institution. Much of the terminology used in this
Handbook is sourced from Tabers Cyclopedic Medical Dictionary.
The definition, implementation, and interpretation of national guidelines for
the treatment of various medical conditions changes as new information and
new technology emerge.The publication of updated information may at times
be contentious among the professional institutions that offer either support
or dissent for the proposed changes.This can cause confusion when a patient
asks questions about how their condition will be identified and managed.The
authors believe that the most important discussion about health care occurs
between the patient and their health-care provider(s). While the individual
studies may point out various screening tests used to identify a disease, the
authors often refer the reader to Websites maintained by nationally recog-
nized authorities on a specific topic that reflect the most current information
and recommendations for screening, diagnosis, and treatment.
Most institutions have established policies, protocols, and interdisciplinary
teams that provide for efficient and effective patient care within the appro-
priate scope of practice. While it is not our intention that the actual duties a
nurse may perform be misunderstood by way of misinterpreted inferences in
writing style, the information prepared by the authors considers that s pecific
limitations are understood by the licensed professionals and other team mem-
bers involved in patient care activities and that the desired outcomes are
achieved by order of the appropriate health-care provider.

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Preface

Laboratory and diagnostic testing. The words themselves often conjure up


cold and impersonal images of needles, specimens lined up in collection con-
tainers, and high-tech electronic equipment. But they do not stand alone. They
are tied to, bound with, and tell of health or disease in the blood and tissue of
a person. Laboratory and diagnostic studies augment the health-care providers
assessment of the quality of an individuals physical being.Test results guide the
plans and interventions geared toward strengthening lifes quality and endur-
ance. Beyond the pounding noise of the MRI, the cold steel of the x-ray table,
the sting of the needle, the invasive collection of fluids and tissue, and the
probing and inspection is the gathering of evidence that supports the health-
care providers ability to discern the course of a disease and the progression of
its treatment. Laboratory and diagnostic data must be viewed with thought and
compassion, however, as well as with microscopes and machines. We must
remember that behind the specimen and test result is the person from whom
it came, a person who is someones son, daughter, mother, father, husband, wife,
or friend.
This book is written to help health-care providers in their understanding
and interpretation of laboratory and diagnostic procedures and their outcomes.
Just as important, it is dedicated to all health-care professionals who experience
the wonders in the science of laboratory and diagnostic testing, performed and
interpreted in a caring and efficient manner.
The authors have continued to enhance four areas in this new edition:
pathophysiology that affects test results, patient safety, patient education, and
integration of related laboratory and diagnostic testing.
First, the Potential Diagnosis section includes an explanation of increased
or decreased values, as many of you requested. We have added age-specific
reference values for the neonatal, pediatric, and geriatric populations at the
request of some of our readers. It should be mentioned that standardized infor-
mation for the complexity of a geriatric population is difficult to document.
Values may be increased or decreased in older adults due to the sole or com-
bined effects of malnutrition, alcohol use, medications, and the presence of
multiple chronic or acute diseases with or without muted symptoms.
Second, the authors appreciate that nurses are the strongest patient advo-
cates with a huge responsibility to protect the safety of their patients, and we
have observed student nurses in clinical settings being interviewed by facility
accreditation inspectors, so we have updated safety reminders, particularly
with respect to positive patient identification, communication of critical infor-
mation, proper timing of diagnostic procedures, rescheduling of specimen
collection for therapeutic drug monitoring, use of evidence-based practices for
prevention of surgical site infections, information regarding the move to track
or limit exposure to radiation from CT studies for adults, and the Image Gently
campaign for pediatric patients who undergo diagnostic studies that utilize
radiation. The pretest section reminds the nurse to positively identify the
patient before providing care, treatment, or services. The pretest section also
addresses hand-off communication of critical information.
The third area of emphasis coaches the student to focus on patient educa-
tion and prepares the nurse to anticipate and respond to a patients questions
or concerns: describing the purpose of the procedure, addressing concerns

xv

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xvi Preface

about pain, understanding the implications of the test results, and describing
post-procedural care. Various related Websites for patient education are includ-
ed throughout the book.
And fourth, laboratory and diagnostic tests do not stand on their ownall
the pieces fit together to form a picture. The section at the end of each mono-
graph integrates both laboratory and diagnostic tests, providing a more com-
plete picture of the studies that may be encountered in a patients health-care
experience. The authors thought it useful for a nurse to know what other tests
might be ordered togetherand all the related tests are listed alphabetically for
ease of use.
Laboratory and diagnostic studies are essential components of a complete
patient assessment. Examined in conjunction with an individuals history and
physical examination, laboratory studies and diagnostic data provide clues
about health status. Nurses are increasingly expected to integrate an under-
standing of laboratory and diagnostic procedures and expected outcomes in
assessment, planning, implementation, and evaluation of nursing care. The data
help develop and support nursing diagnoses, interventions, and outcomes.
Nurses may interface with laboratory and diagnostic testing on several
levels, including:
Interacting with patients and families of patients undergoing diagnostic tests
or procedures, and providing pretest, intratest, and posttest information and
support
Maintaining quality control to prevent or eliminate problems that may
interfere with the accuracy and reliability of test results
Providing education and emotional support at the point of care
Ensuring completion of testing in a timely and accurate manner
Collaborating with other health-care professionals in interpreting findings as
they relate to planning and implementing total patient care
Communicating significant alterations in test outcomes to appropriate health-
care team members
Coordinating interdisciplinary efforts
Whether the nurses role at each level is direct or indirect, the underlying
responsibility to the patient, family, and community remains the same.
The authors hope that the changes and additions made to the book and its
Web-based ancillaries will reward users with an expanded understanding of
and appreciation for the place laboratory and diagnostic testing holds in the
provision of high-quality nursing care and will make it easy for instructors to
integrate this important content in their curricula. The authors would like to
thank all the users of the previous editions for helping us identify what they
like about this book as well as what might improve its value to them. We want
to continue this dialogue. As writers, it is our desire to capture the interest of
our readers, to provide essential information, and to continue to improve the
presentation of the material in the book and ancillary products. We encourage
our readers to provide feedback to the Website and to the publishers sales
professionals. Your feedback helps us modify the materialto change with
your changing needs.

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Reviewers

Nell Britton, MSN, RN, CNE Martha Olson, RN, BSN, MS


Nursing Faculty Nursing Associate Professor
Trident Technical College Nursing Iowa Lakes Community College
Division Emmetsburg, Iowa
Charleston, South Carolina
Barbara Thompson, RN, BScN,
Cheryl Cassis, MSN, RN MScN
Professor of Nursing Professor of Nursing
Belmont Technical College Sault College
St. Clairsville, Ohio Sault Ste. Marie, Ontario

Pamela Ellis, RN, MSHCA, MSN Edward C.Walton, MS, APN-C, NP-C
Nursing Faculty Assistant Professor of Nursing
Mohave Community College Richard Stockton College of
Bullhead City, Arizona New Jersey
Galloway, New Jersey
Stephanie Franks, MSN, RN
Professor of Nursing Jean Ann Wilson, RN, BSN
St. Louis Community CollegeMeramec Coordinator Norton Annex
St. Louis, Missouri Colby Community College
Norton, Kansas
Linda Lott, MSN
AD Nursing Instructor
Itawamba Community College
Fulton, Mississippi

xvii

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Contents

Dedication v
About This Book vii
Preface xv
Reviewers xvii
Monographs 1
System Tables 1613
APPENDIX A
Patient Preparation and Specimen Collection 1628
APPENDIX B
Laboratory Critical Findings 1644
APPENDIX C
Diagnostic Critical Findings 1654
Index 1656

Available on http://davisplus.fadavis.com:
APPENDIX D: Potential Nursing Diagnoses Associated with Laboratory
Diagnostic Testing
APPENDIX E: Guidelines for Age-Specific Communication
APPENDIX F: Transfusion Reactions: Laboratory Findings and Potential
Nursing Interventions
APPENDIX G: Introduction to CLIA
APPENDIX H: Effects of Natural Products on Laboratory Values
APPENDIX I: Standard and Universal Precautions
Bibliography

xix

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Adrenocorticotropic Hormone
Acetylcholine
(and Receptor Antibody
Challenge Tests)
SYNONYM/ACRONYM: AChR (AChR-binding antibody, AChR-blocking antibody,
and AChR-modulating antibody).
A a
COMMON USE: To assist in confirming the diagnosis of myasthenia gravis (MG).

SPECIMEN: Serum (1 mL) collected in a red-top tube.

NORMAL FINDINGS: (Method: Radioimmunoassay) AChR-binding antibody: Less


than 0.4 nmol/L, AChR-blocking antibody: Less than 25% blocking, and AChR-
modulating antibody: Less than 30% modulating.

DESCRIPTION: Normally when Approximately 10% to 15% of


impulses travel down a nerve, the people with confirmed MG do
nerve ending releases a neu- not demonstrate detectable levels
rotransmitter called acetylcholine of AChR-binding, -blocking, or
(ACh), which binds to receptor -modulating antibodies. MG is an
sites in the neuromuscular junc- acquired autoimmune disorder
tion, eventually resulting in muscle that can occur at any age. Its exact
contraction. Once the neuromus- cause is unknown, and it seems to
cular junction is polarized, ACh is strike women between ages 20
rapidly metabolized by the enzyme and 40 years; men appear to be
acetylcholinesterase. When pres- affected later in life than women.
ent, AChR-binding antibodies can It can affect any voluntary muscle,
activate complement and create a but muscles that control eye, eye-
complex of ACh, AChR-binding lid, facial movement, and swallow-
antibodies, and complement. This ing are most frequently affected.
complex renders ACh unavailable Antibodies may not be detected in
for muscle receptor sites. If the first 6 to 12 months after the
AChRbinding antibodies are not first appearance of symptoms. MG
detected, and myasthenia gravis is a common complication associ-
(MG) is strongly suspected, AChR- ated with thymoma. The relation-
blocking and AChR-modulating ship between the thymus gland
antibodies may be ordered. AChR- and MG is not completely under-
blocking antibodies impair or stood. It is believed that miscom-
prevent ACh from attaching to munication in the thymus gland
receptor sites on the muscle mem- directed at developing immune
brane, resulting in poor muscle con- cells may trigger the development
traction.AChR-modulating antibodies of autoantibodies responsible for
destroy AChR sites, interfering MG. Remission after thymectomy
with neuromuscular transmission. is associated with a progressive
The lack of ACh bound to muscle decrease in antibody level. Other
receptor sites results in muscle markers used in the study of MG
weakness. Antibodies to AChR sites include striational muscle antibod-
are present in 90% of patients with ies, thyroglobulin, HLA-B8, and
generalized MG and in 55% to 70% HLA-DR3. These antibodies are
of patients who either have ocular often undetectable in the early
forms of MG or are in remission. stages of MG.

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2 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

This procedure is in the thymus gland directed at


contraindicated for developing immune cells may
Patients who have received trigger the development of auto-
A radioactive scans or radiation antibodies responsible for MG.)
within 1 wk of the test. Results may Decreased in
be invalidated when radioimmuno- Postthymectomy (The thymus
assay is the test method. gland produces the T lymphocytes
Appropriate timing when schedul- responsible for cell-mediated
ing multiple studies should be immunity. T cells also help control
taken into consideration. B-cell development for the produc-
tion of antibodies. T-cell response
INDICATIONS is directed at cells in the body
Confirm the presence but not the that have been infected by bacte-
severity of MG ria, viruses, parasites, fungi, or
Detect subclinical MG in the pres- protozoans. T cells also provide
ence of thymoma immune surveillance for cancer-
Monitor the effectiveness of immu- ous cells. Removal of the thymus
nosuppressive therapy for MG gland is strongly associated
Monitor the remission stage of MG with a decrease in AChR
antibody levels.)
POTENTIAL DIAGNOSIS
Increased in CRITICAL FINDINGS: N/A
Autoimmune liver disease
Generalized MG (Defective trans- INTERFERING FACTORS
mission of nerve impulses to Drugs that may increase AChR
muscles evidenced by muscle levels include penicillamine
weakness. It occurs when normal (long-term use may cause a
communication between the reversible syndrome that produces
nerve and muscle is interrupted clinical, serological, and electro-
at the neuromuscular junction. physiological findings indistinguish-
It is believed that miscommunica- able from MG).
tion in the thymus gland directed Biological false-positive results may
at developing immune cells be associated with amyotrophic lat-
may trigger the development eral sclerosis, autoimmune hepatitis,
of autoantibodies responsible Lambert-Eaton myasthenic syn-
for MG.) drome, primary biliary cirrhosis,
Lambert-Eaton myasthenic and encephalomyeloneuropathies
syndrome associated with carcinoma of
Primary lung cancer the lung.
Thymoma associated with MG Immunosuppressive therapy is the
(Defective transmission of recommended treatment for MG;
nerve impulses to muscles evi- prior immunosuppressive drug
denced by muscle weakness. It administration may result in nega-
occurs when normal communi- tive test results.
cation between the nerve and Recent radioactive scans or radiation
muscle is interrupted at the within 1 wk of the test can interfere
neuromuscular junction. It is with test results when radioimmuno-
believed that miscommunication assay is the test method.

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Acetylcholine Receptor Antibody 3

NURSING IMPLICATIONS AND PROCEDURE


Potential Nursing Problems:
A
Problem Signs & Symptoms Interventions
Urination Urinary retention; Assess amount of fluid intake as it
(Related to urinary frequency; may be necessary to limit fluids
neurogenic urinary urgency; to control incontinence; assess
bladder; pain and abdominal risk of urinary tract infection with
spastic distention; urinary limiting oral intake; begin bladder
bladder; dribbling training program; teach
associated catheterization techniques to
with disease family and patient
process) self-catheterization
Self-care Difficulty fastening Reinforce self-care techniques as
(Related to clothing; difficulty taught by occupational therapy;
spasticity; performing personal ensure the patient has adequate
altered level hygiene; inability to time to perform self-care;
of conscious maintain encourage use of assistive
ness; paresis; appropriate devices to maintain
increasing appearance; independence; assess ability to
weakness; difficulty with perform ADLs; provide care
paralysis) independent assistance appropriate to
mobility; declining degree of disability while
physical function maintaining as much
independence as possible
Mobility Unsteady gait; lack of Assess gait; assess muscle
(Related to coordination; strength; assess weakness and
weakness; difficult purposeful coordination; assess physical
tremors; movement; endurance and level of fatigue;
spasticity) inadequate range assess ability to perform
of motion independent ADLs; assess ability
for safe, independent movement;
identify need for assistive device;
encourage safe self-care
Pain (Related Self-report of pain; Keep the immediate environment
to motor and emotional symptoms cool to decrease aggravating
sensory of distress; crying; MG symptoms; use passive or
nerve agitation; facial active range of motion to
damage grimace; moaning; decrease muscle tightness;
associated verbalization of pain; administer analgesics,
with disease rocking motions; tranquilizers, antispasmodics,
process) irritability; disturbed and neuropathic pain medication,
sleep; diaphoresis; as ordered
altered blood
pressure and heart
rate; nausea;
vomiting

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4 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

PRETEST: Remove the needle and apply direct


Positively identify the patient using at pressure with dry gauze to stop bleed-
least two unique identifiers before pro- ing. Observe/assess venipuncture site
viding care, treatment, or services. for bleeding or hematoma formation and
A secure gauze with adhesive bandage.
Patient Teaching: Inform the patient that
the test is used to identify antibodies Promptly transport the specimen to
responsible for decreased neuromus- the laboratory for processing and
cular transmission and associated analysis.
muscle weakness. POST-TEST:
Obtain a history of the patients com-
Inform the patient that a report of the
plaints, including a list of known aller-
results will be made available to the
gens, especially allergies or sensitivities
requesting health-care provider (HCP),
to latex, and any prior complications
who will discuss the results with the
with general anesthesia.
patient.
Obtain a history of the patients musculo-
Recognize anxiety related to test
skeletal system, symptoms, and results
results, and be supportive of activity
of previously performed laboratory tests
challenges related to lack of neuromus-
and diagnostic and surgical procedures.
cular control, anticipated loss of inde-
Note any recent procedures that can
pendence, and fear of death. It is
interfere with test results.
important to note that a diagnosis of
Obtain a list of the patients current
MG should be based on abnormal find-
medications, including herbs, nutri-
ings from two different diagnostic tests.
tional supplements, and nutraceuticals
These tests include AChR antibody
(see Appendix H online at DavisPlus).
assay, anti-MuSK antibody assay (an
Review the procedure with the patient.
antibody which is produced in 40% to
Inform the patient that specimen col-
70% of the remaining 15% who have
lection takes approximately 5 to 10 min.
MG but test negative for AChR anti-
Address concerns about pain and
body), edrophonium test (which involves
explain that there may be some dis-
injection of edrophonium or tensilon, a
comfort during the venipuncture.
medication that temporarily blocks the
Sensitivity to social and cultural issues,
degradation of acetylcholine, allowing
as well as concern for modesty, is
normal measurable neuromuscular
important in providing psychological
transmission that dissipates as the
support before, during, and after the
effects of the injection wear off), repeti-
procedure.
tive nerve stimulation (small pulses of
Note that there are no food, fluid, or
electricity are repeatedly sent to specific
medication restrictions unless by medi-
muscles by way of electrodes to mea-
cal direction.
sure a decrease in response due to
INTRATEST: muscle weakening), and single-fiber
electromyography (see EMG mono-
Potential Complications: N/A
graph for more detailed information).
Avoid the use of equipment containing Discuss the implications of positive test
latex if the patient has a history of aller- results on the patients lifestyle. Positive
gic reaction to latex. test results may lead to testing for other
Instruct the patient to cooperate fully conditions associated with MG.
and to follow directions. Direct the Thyrotoxicosis may occur in conjunction
patient to breathe normally and to with MG; related thyroid testing may be
avoid unnecessary movement. indicated. MG patients may also pro-
Observe standard precautions, and fol- duce antibodies, such as antinuclear
low the general guidelines in Appendix A. antibody and rheumatoid factor, not pri-
Positively identify the patient, and label marily associated with MG that demon-
the appropriate specimen container strate measurable reactivity.
with the corresponding patient demo- Evaluate test results in relation to
graphics, initials of the person collect- future general anesthesia, especially
ing the specimen, date, and time of regarding therapeutic management of
collection. Perform a venipuncture. MG with cholinesterase inhibitors.

Monograph_A_001-023.indd 4 17/11/14 12:03 PM


Acid Phosphatase, Prostatic 5

Succinylcholine-sensitive patients may Teach the family and patient that


be unable to metabolize the anesthetic assistive devices can improve quality
quickly, resulting in prolonged or of life and decrease injury risk.
unrecoverable apnea.
Provide contact information, if desired, Expected Patient Outcomes: A
for the Myasthenia Gravis Foundation Knowledge
of America (www.myasthenia.org) and The patient and family verbalize
the Muscular Dystrophy Association understanding that spasms can be
(www.mdausa.org). decreased by adhering to
Depending on the results of this recommended physical therapy.
procedure, additional testing may be The patient and family describe the
performed to evaluate or monitor pro- necessity to promote independent
gression of the disease process and self-care while seeking assistance as
determine the need for a change in necessary to prevent injury.
therapy. If a diagnosis of MG is made, Skills
a computed tomography (CT) scan of The patient and family demonstrate the
the chest should be performed to rule ability to perform passive and active
out thymoma. Evaluate test results in range of motion activities.
relation to the patients symptoms The patient and family demonstrate
and other tests performed. how to apply splints to hands to help
Patient Education: control hand spasms.
Discuss the implications of positive test Attitude
results on the patients lifestyle. The patient and family set personal
Provide teaching and information goals regarding performance of
regarding the clinical implications of the self-care activities that are in realistic
test results, as appropriate. proportion to disease progression.
Educate the patient regarding access The patient and family accept the
to counseling services. physical limitations related to the
Reinforce information given by the disease process.
patients health-care provider (HCP)
RELATED MONOGRAPHS:
regarding further testing, treatment, or
referral to another HCP. Related tests include ANA, antithyroglob-
Answer any questions or address any ulin and antithyroid peroxidase antibodies,
concerns voiced by the patient or family. CT chest, myoglobin, pseudocholines-
Teach family to place self-care items terase, RF, TSH, and total T4.
within the patients reach to promote Refer to the Musculoskeletal System
as much independence in care as table at the end of the book for related
possible. tests by body system.

Acid Phosphatase, Prostatic


SYNONYM/ACRONYM: Prostatic acid phosphatase, o-phosphoric monoester phos-
phohydrolase, PAcP PAP.

COMMON USE: To assist in staging prostate cancer and document evidence of


sexual intercourse through semen identification in alleged cases of rape and
sexual abuse.

SPECIMEN: Serum (1 mL) collected in a gold-, red-, or red/gray-top tube. Place


separated serum into a standard transport tube within 2 hr of collection.
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6 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

A swab with vaginal secretions may be submitted in the appropriate trans-


fer container. Other material such as clothing may be submitted for analysis.
Consult the laboratory or emergency services department for the proper
A specimen collection instructions and containers.

NORMAL FINDINGS: (Method: Immunochemiluminometric)

(sickle cell crisis) also reflect


Conventional & SI Units increased levels.
Less than 3.5 ng/mL Acute myelogenous leukemia
Values are elevated at birth, decrease by 6 mo, After prostate surgery or biopsy
increase at approximately 10 yr through Benign prostatic hypertrophy
puberty, level off through adulthood, and may Liver disease
increase in advancing age. Lysosomal storage diseases
This procedure is (Gauchers disease and Niemann-Pick
contraindicated for: N/A disease) (PAcP is stored in the
lysosomes of blood cells, and
POTENTIAL DIAGNOSIS increased levels are present in
lysosomal storage diseases)
Increased in Metastatic bone cancer
PAcP is released from any dam- Pagets disease
aged cell in which it is stored, so Prostatic cancer
diseases of the bone, prostate, and Prostatic infarct
liver that cause cellular destruc- Prostatitis
tion demonstrate elevated PAcP Sickle cell crisis
levels. Conditions that result in Thrombocytosis
abnormal elevations of cells that
contain PAcP (e.g., leukemia, Decreased in: N/A
thrombocytosis) or conditions that
result in rapid cellular destruction CRITICAL FINDINGS: N/A
Find and print out the full monograph at DavisPlus (http://davisplus.fadavis
.com, keyword Van Leeuwen).

Adrenal Gland Scan


SYNONYM/ACRONYM: Adrenal scintiscan.

COMMON USE: To assist in the diagnosis of Cushings syndrome and differentiate


between adrenal gland cancer and infection.

AREA OF APPLICATION: Adrenal gland.

CONTRAST: Intravenous radioactive NP-59 (iodomethyl-19-norcholesterol) or


metaiodobenzylguanidine (MIBG).

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Adrenal Gland Scan 7

Conditions associated with


DESCRIPTION:This nuclear medi- adverse reactions to contrast
cine study evaluates the function medium (e.g., asthma, food
of the adrenal glands. The secre-
tory function of the adrenal glands
allergies, or allergy to contrast A
medium).
is controlled primarily by the Although patients are still asked
anterior pituitary, which produces specifically if they have a known
adrenocorticotropic hormone allergy to iodine or shellfish, it has
(ACTH). ACTH stimulates the adre- been well established that the reac-
nal cortex to produce cortisone tion is not to iodine; in fact, an
and secrete aldosterone. Adrenal actual iodine allergy would be very
imaging is most useful in differen- problematic because iodine is
tiation of hyperplasia from adeno- required for the production of thy-
ma in primary aldosteronism roid hormones. In the case of shell-
when computed tomography fish, the reaction is to a muscle pro-
(CT) and magnetic resonance tein called tropomyosin; in the case
imaging (MRI) findings are of iodinated contrast medium, the
equivocal. High concentrations of reaction is to the noniodinated part
cholesterol (the precursor in the of the contrast molecule. Patients
synthesis of adrenocorticoste- with a known hypersensitivity to
roids, including aldosterone) are the medium may benefit from pre-
stored in the adrenal cortex and medication with corticosteroids
this allows the radionuclide, and diphenhydramine; the use of
which attaches to the cholesterol, nonionic contrast or an alternative
to be used in identifying patholo- noncontrast imaging study, if avail-
gy in the secretory function of able, may be considered for
the adrenal cortex. The uptake of patients who have severe asthma
the radionuclide occurs gradually or who have experienced moderate
over time and imaging is per- to severe reactions to ionic contrast
formed within 24 to 48 hr of medium.
radionuclide injection and contin-
ued daily for 3 to 5 days. Imaging
can reveal increased uptake, INDICATIONS
unilateral or bilateral uptake, or Aid in the diagnosis of Cushings
absence of uptake in the detec- syndrome and aldosteronism
tion of pathological processes. Aid in the diagnosis of gland tissue
Following prescanning treatment destruction caused by infection,
with corticosteroids, suppression infarction, neoplasm, or
studies can also be done to differ- suppression
entiate the presence of tumor Aid in locating adrenergic
from hyperplasia of the glands. tumors
Determine adrenal suppressibility
with prescan administration of cor-
This procedure is ticosteroid to diagnose and localize
contraindicated for adrenal adenoma, aldosteronomas,
Patients who are pregnant or androgen excess, and low-renin
suspected of being pregnant, hypertension
unless the potential benefits of a Differentiate between asymmetric
procedure using radiation far out- hyperplasia and asymmetry from
weigh the risk of radiation expo- aldosteronism with dexamethasone
sure to the fetus and mother. suppression test

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8 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

POTENTIAL DIAGNOSIS Safety in Pediatric Imaging


(www.pedrad.org/associations/
Normal findings in
5364/ig/).
No evidence of tumors, infection,
A Risks associated with radiation
infarction, or suppression
overexposure can result from fre-
Normal bilateral uptake of radionu-
quent x-ray or radionuclide proce-
clide and secretory function of
dures. Personnel working in the
adrenal cortex
examination area should wear
Normal salivary glands and urinary
badges to record their radiation
bladder; vague shape of the liver
exposure level.
and spleen sometimes seen

Abnormal findings in
Adrenal gland suppression
Adrenal infarction NURSING IMPLICATIONS
Adrenal tumor AND PROCEDURE
Hyperplasia
PRETEST:
Infection
Pheochromocytoma Positively identify the patient using at
least two unique identifiers before pro-
viding care, treatment, or services.
CRITICAL FINDINGS: N/A Patient Teaching: Inform the patient this
procedure can visualize and assess the
function of the adrenal gland, which is
INTERFERING FACTORS located near the kidney.
Factors that may impair Obtain a history of the patients com-
clear imaging plaints or clinical symptoms, including
a list of known allergens, especially
Retained barium from a previous allergies or sensitivities to latex, anes-
radiological procedure. thetics, contrast medium, or sedatives.
Inability of the patient to cooperate Obtain a history of the patients endo-
or remain still during the proce- crine system, symptoms, and results of
dure because of age, significant previously performed laboratory tests
pain, or mental status. and diagnostic and surgical procedures.
Perform all adrenal blood tests before
Other considerations doing this test.
Improper injection of the radionu- Record the date of last menstrual
clide may allow the tracer to seep period and determine the possibility of
deep into the muscle tissue, pro- pregnancy in perimenopausal women.
Obtain a list of the patients current
ducing erroneous hot spots. medications, including herbs, nutri-
Consultation with a health-care pro- tional supplements, and nutraceuticals
vider (HCP) should occur before (see Appendix H online at DavisPlus).
the procedure for radiation safety If iodinated contrast medium is
concerns regarding younger scheduled to be used in patients
patients or patients who are lactat- receiving metformin (Glucophage) for
ing. Pediatric & Geriatric Imaging noninsulin-dependent (type 2) diabe-
Children and geriatric patients are tes, the drug should be discontinued
on the day of the test and continue to
at risk for receiving a higher radia-
be withheld for 48 hr after the test.
tion dose than necessary if settings Iodinated contrast can temporarily
are not adjusted for their small size. impair kidney function, and failure to
Pediatric Imaging Information on withhold metformin may indirectly
the Image Gently Campaign can be result in drug-induced lactic acidosis,
found at the Alliance for Radiation a dangerous and sometimes fatal side

Monograph_A_001-023.indd 8 17/11/14 12:03 PM


Adrenal Gland Scan 9

effect of metformin (related to Avoid the use of equipment containing


renal impairment that does not latex if the patient has a history of
support sufficient excretion allergic reaction to latex.
of metformin). Observe standard precautions, and
Review the procedure with the patient. follow the general guidelines in A
Address concerns about pain and Appendix A. Positively identify the
explain that there may be moments of patient.
discomfort and some pain experienced Ensure that the patient has removed
during the test. Inform the patient that external metallic objects from the area
the procedure is usually performed in a to be examined prior to the procedure.
nuclear medicine department by a Have emergency equipment readily
nuclear medicine technologist with sup- available.
port staff, and it takes approximately Instruct the patient to void prior to
1 to 2 hr each day. Inform the patient the the procedure and to change into
test usually involves a prolonged scan- the gown, robe, and foot coverings
ning schedule over a period of days. provided.
Administer saturated solution of Insert an IV line, and inject the radionu-
potassium iodide (SSKI or Lugol clide IV on day 1; images are taken on
iodine solution) 24 hr before the study days 1, 2, and 3. Imaging is done from
to prevent thyroid uptake of the free the urinary bladder to the base of the
radioactive iodine. skull to scan for a primary tumor. Each
Sensitivity to social and cultural issues, image takes 20 min, and total imaging
as well as concern for modesty, is time is 1 to 2 hr per day.
important in providing psychological Instruct the patient to cooperate fully
support before, during, and after the and to follow directions. Instruct the
procedure. patient to remain still throughout the
Explain that an IV line may be inserted to procedure because movement pro-
allow infusion of IV fluids such as normal duces unreliable results.
saline, anesthetics, sedatives, contrast
medium, or emergency medications. POST-TEST:
Note that there are no food, fluid, or Inform the patient that a report of the
medication restrictions unless by medi- results will be made available to the
cal direction. requesting HCP, who will discuss the
Instruct the patient to remove jewelry results with the patient.
and other metallic objects from the Advise the patient to drink increased
area to be examined. amounts of fluids for 24 to 48 hrs to
Make sure a written and informed eliminate the radionuclide from the
consent has been signed prior to the body, unless contraindicated. Inform
procedure and before administering the patient that radionuclide is elimi-
any medications. nated from the body within 24 to 48 hr.
INTRATEST: Do not schedule other radionuclide
tests 24 to 48 hr after this procedure.
Potential Complications: Observe/assess the needle site for
Injection of the contrast is an invasive bleeding, hematoma formation, and
procedure. Complications are rare but inflammation.
do include risk for: allergic reaction Instruct the patient in the care and
(related to contrast reaction), hema- assessment of the injection site.
toma (related to blood leakage into Instruct the patient to apply cold com-
the tissue following needle insertion), presses to the puncture site as needed
bleeding from the puncture site to reduce discomfort or edema.
(related to a bleeding disorder, or the If a woman who is breast-feeding must
effects of natural products and medi- have a nuclear scan, she should not
cations known to act as blood thin- breast-feed the infant until the radio-
ners), or infection (which might occur nuclide has been eliminated. This
if bacteria from the skin surface is could take as long as 3 days. Instruct
introduced at the puncture site). her to express the milk and discard it

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10 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

during the 3-day period to prevent 10 days after the injection of the
cessation of milk production. radionuclide. Answer any questions or
Instruct the patient to immediately flush address any concerns voiced by the
the toilet and to meticulously wash patient or family.
A hands with soap and water after each Depending on the results of this pro-
voiding for 48 hrs after the procedure. cedure, additional testing may be
Instruct all caregivers to wear gloves needed to evaluate or monitor pro-
when discarding urine for 48 hrs after gression of the disease process and
the procedure. Wash gloved hands determine the need for a change in
with soap and water before removing therapy. Evaluate test results in rela-
gloves. Then wash ungloved hands tion to the patients symptoms and
after the gloves are removed. other tests performed.
Recognize anxiety related to test
results. Discuss the implications of RELATED MONOGRAPHS:
abnormal test results on the patients Related tests include ACTH and chal-
lifestyle. Provide teaching and informa- lenge tests, aldosterone, angiography
tion regarding the clinical implications adrenal, catecholamines, CT abdomen,
of the test results, as appropriate. cortisol and challenge tests, HVA, MRI
Reinforce information given by the abdomen, metanephrines, potassium,
patients HCP regarding further test- renin, sodium, and VMA.
ing, treatment, or referral to another Refer to the Endocrine System table at
HCP. Advise the patient that SSKI the end of the book for related tests by
(120 mg/day) will be administered for body system.

Adrenocorticotropic Hormone
(and Challenge Tests)
SYNONYM/ACRONYM: Corticotropin, ACTH.

COMMON USE: To assist in the investigation of adrenocortical dysfunction using


ACTH and cortisol levels in diagnosing disorders such as Addisons disease,
Cushings disease, and Cushings syndrome.

SPECIMEN: Plasma (2 mL) from a lavender-top (EDTA) tube for adrenocorti-


cotropic hormone (ACTH) and serum (1 mL) from a red-top tube for cortisol
and 11-deoxycortisol. Collect specimens in a prechilled lavender- and red-
top tubes. Gold-tiger- and green-top (heparin) tubes are also acceptable for
cortisol, but take care to use the same type of collection container for serial
measurements. Immediately transport specimen, tightly capped and in an ice
slurry, to the laboratory. The specimens should be immediately processed.
Plasma for ACTH analysis should be transferred to a plastic container.

Monograph_A_001-023.indd 10 17/11/14 12:03 PM


Medication Administered,
Procedure Indications Adult Dosage Recommended Collection Times
ACTH Suspect adrenal insufficiency (Addisons 1 mcg (low-dose Three cortisol levels: baseline immediately before
stimulation, disease) or congenital adrenal hyperplasia physiologic protocol) bolus, 30 min after bolus, and 60 min (optional)
rapid test cosyntropin IM or IV; after bolus.

Monograph_A_001-023.indd 11
250 mcg (standard Baseline and 30 min levels are adequate for
pharmacologic protocol) accurate diagnosis using either dosage; low
cosyntropin IM or IV dose protocol sensitivity is most accurate for
30 min level only
Corticotropin- Differential diagnosis between ACTH- IV dose of 1 mcg/kg Eight cortisol and eight ACTH levels: baseline
releasing dependent conditions such as Cushings human CRH collected 15 min before injection, 0 min before
hormone disease (pituitary source) or Cushings injection, and then 5, 15, 30, 60, 120, and
(CRH) syndrome (ectopic source) and ACTH- 180 min after injection
stimulation independent conditions such as Cushings
syndrome (adrenal source)
Dexameth Differential diagnosis between ACTH- Oral dose of 1 mg Collect cortisol at 8 a.m. on the morning after
asone dependent conditions such as Cushings dexamethasone the dexamethasone dose
suppression disease (pituitary source) or Cushings (Decadron) at 11 p.m.
(overnight) syndrome (ectopic source) and ACTH-
independent conditions such as Cushings
syndrome (adrenal source)
Metyrapone Suspect hypothalamic/pituitary disease such Oral dose of 30 mg/kg Collect cortisol, 11-deoxycortisol, and ACTH at
stimulation as adrenal insufficiency, ACTH-dependent metyrapone with snack 8 a.m. on the morning after the metyrapone
(overnight) conditions such as Cushings disease at midnight dose
(pituitary source) or Cushings syndrome
(ectopic source), and ACTH-independent
conditions such as Cushings syndrome
Adrenocorticotropic Hormone (and Challenge Tests)

(adrenal source)
11

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IM = intramuscular, IV = intravenous.
A

17/11/14 12:03 PM
12 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

NORMAL FINDINGS: (Method: Immunochemiluminescent assay for ACTH and


cortisol; HPLC/MS-MS for 11-deoxycortisol)

A ACTH

Conventional SI Units (Conventional


Age Units Units 0.22)
Cord blood 50570 pg/mL 11125 pmol/L
Newborn 10185 pg/mL 241 pmol/L
1 wk9 yr 546 pg/mL 1.110.1 pmol/L
1018 yr 655 pg/mL 1.312.1 pmol/L
19 yrAdult
Male supine (specimen collected 769 pg/mL 1.515.2 pmol/L
in morning)
Female supine (specimen 658 pg/mL 1.312.8 pmol/L
collected in morning)

Values may be unchanged or slightly elevated in healthy older adults. Long-term use of
corticosteroids, to treat arthritis and autoimmune diseases, may suppress secretion of ACTH.

ACTH Challenge Tests

ACTH (Cosyntropin) SI Units (Conventional


Stimulated, Rapid Test Conventional Units Units 27.6)
Baseline Cortisol greater than Greater than 138 nmol/L
5 mcg/dL
30- or 60-min response Cortisol 1820 mcg/dL 497552 nmol/L or
or incremental incremental increase of
increase of 7 mcg/dL 193.2 nmol/L over
over baseline value baseline value

Corticotropin-
Releasing Hormone SI Units (Conventional
Stimulated Conventional Units Units 27.6)
Cortisol peaks at Greater than 552 nmol/L
greater than
20 mcg/dL within
3060 min
SI Units (Conventional
Units 0.22)
ACTH increases Twofold to fourfold increase
twofold to fourfold within 3060 min
within 3060 min

Monograph_A_001-023.indd 12 17/11/14 12:03 PM


Adrenocorticotropic Hormone (and Challenge Tests) 13

Dexamethasone
Suppressed SI Units (Conventional
Overnight Test Conventional Units Units 27.6)
A
Cortisol less than Less than 49.7 nmol/L
1.8 mcg/dL next day

Metyrapone
Stimulated SI Units (Conventional
Overnight Test Conventional Units Units 27.6)
Cortisol less than Less than 83 nmol/L
3 mcg/dL next day
SI Units (Conventional
Units 0.22)
ACTH greater than 75 pg/mL Greater than 16.5 pmol/L
SI Units (Conventional
Units 28.9)
11-deoxycortisol greater than Greater than 202 nmol/L
7 mcg/dL

DESCRIPTION:Hypothalamic- exhibit a diurnal variation, peak-


releasing factor stimulates the ing between 6 and 8 a.m. and
release of ACTH from the anteri- reaching the lowest point
or pituitary gland. ACTH stimu- between 6 and 11 p.m. Evening
lates adrenal cortex secretion of levels are generally one-half to
glucocorticoids, androgens, and, two-thirds lower than morning
to a lesser degree, mineralocorti- levels. Cortisol levels also vary
coids. Cortisol is the major gluco- diurnally, with the peak values
corticoid secreted by the adrenal occurring during between 6 and
cortex. ACTH and cortisol test 8 a.m. in the morning and reach-
results are evaluated together ing the lowest levels between
because a change in one normal- 8 p.m. and midnight in the eve-
ly causes a change in the other. ning. Specimens are typically col-
ACTH secretion is stimulated by lected at 8 a.m. and 4 p.m. This
insulin, metyrapone, and vaso- pattern may be reversed in indi-
pressin. It is decreased by dexa- viduals who sleep during day-
methasone. Cortisol excess from time hours and are active during
any source is termed Cushings nighttime hours. Salivary cortisol
syndrome. Cortisol excess result- levels are known to parallel
ing from ACTH excess produced blood levels and can be used to
by the pituitary is termed screen for Cushings disease and
Cushings disease. ACTH levels Cushings syndrome.

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14 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

This procedure is as oat-cell carcinoma and large-


contraindicated for cell carcinoma of the lung and
Patients with suspected adre- by benign bronchial carcinoid
A nal insufficiency because it tumor.
may induce an acute adrenal crisis,
a life threatening condition, in Challenge Tests and Results
patients whose adrenal function is The ACTH (cosyntropin) stimulated
already compromised. rapid test directly evaluates adre-
nal gland function and indirectly
evaluates pituitary gland and
INDICATIONS hypothala mus function. Cosyntro
Determine adequacy of replace- pin is a synthetic form of ACTH. A
ment therapy in congenital adrenal baseline cortisol level is collected
hyperplasia before the injection of cosyntropin.
Determine adrenocortical Specimens are subsequently col-
dysfunction lected at 30- and 60-min intervals. If
Differentiate between increased the adrenal glands function nor-
ACTH release with decreased cor- mally, cortisol levels rise signifi-
tisol levels and decreased ACTH cantly after administration of
release with increased cortisol cosyntropin.
levels The CRH stimulation test works
as well as the dexamethasone sup-
pression test (DST) in distinguishing
POTENTIAL DIAGNOSIS
Cushings disease from conditions
in which ACTH is secreted ectopi-
ACTH Result
cally (e.g., tumors not located in
Because ACTH and cortisol secre-
the pituitary gland that secrete
tion exhibit diurnal variation
ACTH). Patients with pituitary
with values being highest in the
tumors tend to respond to CRH
morning, a lack of change in val-
stimulation, whereas those with
ues from morning to evening is
ectopic tumors do not. Patients
clinically significant. Decreased
with adrenal insufficiency dem-
concentrations of hormones
onstrate one of three patterns
secreted by the pituitary gland
depending on the underlying cause:
and its target organs are observed
in hypopituitarism. In primary Primary adrenal insufficiency
adrenal insufficiency (Addisons high baseline ACTH (in response
disease), because of adrenal to IV-administered ACTH) and
gland destruction by tumor, infec- low cortisol levels pre- and post-
tious process, or immune reac- IV ACTH.
tion, ACTH levels are elevated Secondary adrenal insufficiency
while cortisol levels are decreased. (pituitary)low baseline
Both ACTH and cortisol levels are ACTH that does not respond
decreased in secondary adrenal to ACTH stimulation. Cortisol
insufficiency (i.e., secondary to levels do not increase after
pituitary insufficiency). Excess stimulation.
ACTH can be produced ectopically Tertiary adrenal insufficiency
by various lung cancers such (hypothalamic)low baseline

Monograph_A_001-023.indd 14 17/11/14 12:03 PM


Adrenocorticotropic Hormone (and Challenge Tests) 15

ACTH with an exaggerated and disease (e.g., primary or ectopic


prolonged response to stimula- tumor that secretes ACTH) or
tion. Cortisol levels usually do stimulation by physical or emo-
not reach 20 mcg/dL. tional stress, or it can be an indi- A
rect response to abnormalities in
(The DST is useful in differentiat-
the complex feedback mecha-
ing the causes of increased corti-
nisms involving the pituitary
sol levels. Dexamethasone is a
gland, hypothalamus, or adrenal
synthetic glucocorticoid that is
glands.
significantly more potent than
cortisol. It works by negative
feedback. It suppresses the
ACTH Increased in
release of ACTH in patients with a
Addisons disease (primary adre-
normal hypothalamus. A cortisol
nocortical hypofunction)
level less than 1.8 mcg/dL usually
Carcinoid syndrome
excludes Cushing s syndrome.
Congenital adrenal hyperplasia
With the DST, a baseline morning
Cushings disease (pituitary-
cortisol level is collected, and the
dependent adrenal
patient is given a 1-mg dose of
hyperplasia)
dexamethasone at bedtime. A sec-
Cushings syndrome (ectopic
ond specimen is collected the fol-
secretion of ACTH)
lowing morning. If cortisol levels
Depression
have not been suppressed, adre-
Ectopic ACTH-producing tumors
nal adenoma is suspected. The
Menstruation
DST also produces abnormal
Nelsons syndrome
results in the presence of certain
(ACTH-producing pituitary
psychiatric illnesses [e.g., endog-
tumors)
enous depression]).
Non-insulin-dependent diabetes
The metyrapone stimulation
Pregnancy
test is used to distinguish cortico-
Sepsis
tropin-dependent causes (pituitary
Septic shock
Cushings disease and ectopic
Cushings disease) from cortico-
tropin-independent causes (e.g., Decreased in
carcinoma of the lung or thyroid) Secondary adrenal insufficiency
of increased cortisol levels. due to hypopituitarism (inade-
Metyrapone inhibits the conver- quate production by the pitu-
sion of 11-deoxycortisol to corti- itary) can result in decreased
sol. Cortisol levels should decrease levels of ACTH. Conditions that
to less than 3 mcg/dL if normal result in overproduction or avail-
pituitary stimulation by ACTH ability of high levels of cortisol
occurs after an oral dose of metyr- can also result in decreased levels
apone. Specimen collection and of ACTH.
administration of the medication
are performed as with the over-
night dexamethasone test. ACTH Decreased in
Adrenal adenoma
Increased in Adrenal cancer
Overproduction of ACTH can Cushings syndrome
occur as a direct result of either Exogenous steroid therapy

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16 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

Summary of the Relationship Between Cortisol and ACTH Levels in


Conditions Affecting the Adrenal and Pituitary Glands
Disease Cortisol Level ACTH Level
A
Addisons disease (adrenal Decreased Increased
insufficiency)
Cushings disease (pituitary adenoma) Increased Increased
Cushings syndrome related to ectopic Increased Increased
source of ACTH
Cushings syndrome (ACTH independent; Increased Decreased
adrenal cancer or adenoma)
Congenital adrenal hyperplasia Decreased Increased

CRITICAL FINDINGS: N/A Excessive physical activity can


produce elevated levels.
INTERFERING FACTORS Metyrapone may cause gastrointes-
Drugs that may increase ACTH lev- tinal distress and/or confusion.
els include insulin, metoclopramide, Administer oral dose of metyrapone
metyrapone, mifepristone (RU 486), with milk and snack.
and vasopressin. Rapid clearance of metyrapone,
Drugs that may decrease ACTH lev- resulting in falsely increased corti-
els include corticosteroids (e.g., sol levels, may occur if the patient
dexamethasone) and pravastatin. is taking drugs that enhance steroid
Test results are affected by the time metabolism
the test is done because ACTH lev- (e.g., phenytoin, rifampin, pheno-
els vary diurnally, with the highest barbital, mitotane, and corticoste-
values occurring between 6 and 8 roids). The requesting health-care
a.m. and the lowest values occur- provider (HCP) should be consult-
ring at night. Samples should be ed prior to a metyrapone stimula-
collected at the same time of day, tion test regarding a decision to
between 6 and 8 a.m. withhold these medications.

NURSING IMPLICATIONS AND PROCEDURE


Potential Nursing Problems:

Problem Signs & Symptoms Interventions


Fluid volume Deficient: hypotension; Monitor intake and output;
(Related to loss decreased cardiac assess for symptoms of
of water output; decreased dehydration (dry skin, dry
secondary to urinary output; dry mucous membranes, poor
vomiting; skin/mucous skin turgor, sunken eyeballs);
diarrhea) membranes; poor monitor and trend vital signs;
skin turgor; sunken monitor for symptoms of poor
eyeballs; increased cardiac output (rapid, weak,
urine specific gravity; thready pulse); monitor and
hemoconcentration trend daily weight;
collaborate with physician
with administration of IV

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Adrenocorticotropic Hormone (and Challenge Tests) 17

Problem Signs & Symptoms Interventions


fluids to support hydration;
monitor laboratory values that A
reflect alterations in fluid status
(potassium, blood urea
nitrogen, creatinine, calcium,
hemoglobin, and hematocrit,
sodium); manage underlying
cause of fluid alteration;
monitor urine characteristics
and respiratory status;
establish baseline assessment
data; collaborate with physician
to adjust oral and IV fluids to
provide optimal hydration
status; administer replacement
electrolytes, as ordered; adjust
diuretics, as appropriate
Infection risk Delayed wound Decrease exposure to
(Related to healing; inhibited environment by placing the
impaired collagen formation; patient in a private room;
immune impaired blood flow monitor and trend vital signs;
response to edematous monitor and trend laboratory
secondary to tissues; symptoms of values that would indicate an
elevated infection infection (WBC, CRP); promote
cortisol level) (temperature; good hygiene; assist with
increased heart rate; hygiene, as needed; administer
increased blood prescribed antibiotics,
pressure; shaking; antipyretics; use cooling
chills; mottled skin; measures; administer
lethargy; fatigue; prescribed IV fluids; monitor
swelling; edema; vital signs and trend
pain; localized temperatures; encourage oral
pressure; fluids; adhere to standard or
diaphoresis; night universal precautions; isolate as
sweats; confusion; appropriate; obtain cultures, as
vomiting; nausea; ordered; encourage lightweight
headache) clothing and bedding
Injury risk (Related Easy bruising; blood Assess for bruising; assess
to poor wound in stool; skin stool for occult blood; assess
healing; breakdown; fracture; for skin breakdown; assess
decreased bone poor wound healing wound for healing progress;
density; capillary facilitate ordered bone
fragility) density screening

PRETEST: Patient Teaching: Inform the patient this


Positively identify the patient using at test can assist in evaluating the amount
least two unique identifiers before of hormone produced by the pituitary
providing care, treatment, or services. gland located at the base of the brain.

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18 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

Obtain a history of the patients com- pain, headache, dizziness, sedation,


plaints, including a list of known allergens, allergic rash, decreased white blood cell
especially allergies or sensitivities to latex. (WBC) count, and bone marrow depres-
Obtain a history of the patients endocrine sion. Signs and symptoms of overdose
A system, symptoms, and results of previ- or acute adrenocortical insufficiency
ously performed laboratory tests and include cardiac arrhythmias, hypoten-
diagnostic and surgical procedures. sion, dehydration, anxiety, confusion,
Note any recent procedures that can weakness, impairment of conscious-
interfere with test results. ness, N/V, epigastric pain, diarrhea,
Obtain a list of the patients current hyponatremia, and hyperkalemia.
medications, especially drugs that Ensure that strenuous exercise was
enhance steroid metabolism, including avoided for 12 hr before the test and
herbs, nutritional supplements, and that 1 hr of bed rest was taken imme-
nutraceuticals (see Appendix H online diately before the test. Samples should
at DavisPlus). be collected between 6 and 8 a.m.
Weigh patient and report weight to Have emergency equipment readily
pharmacy for dosing of metyrapone available in case of adverse reaction to
(30 mg/kg body weight). metyrapone.
Review the procedure with the patient. Avoid the use of equipment containing
When ACTH hypersecretion is sus- latex if the patient has a history of aller-
pected, a second sample may be gic reaction to latex.
requested between 6 and 8 p.m. to Instruct the patient to cooperate fully
determine if changes are the result of and to follow directions. Direct the
diurnal variation in ACTH levels. Inform patient to breathe normally and to
the patient that more than one sample avoid unnecessary movement.
may be necessary to ensure accurate Observe standard precautions, and
results, and samples are obtained at spe- follow the general guidelines in
cific times to determine high and low lev- Appendix A. Positively identify the
els of ACTH. Inform the patient that each patient, and label the appropriate
specimen collection takes approximately tubes with the corresponding patient
5 to 10 min. Address concerns about demographics, date, and time of col-
pain and explain that there may be some lection. Perform a venipuncture; collect
discomfort during the venipuncture. the specimen in prechilled collection
Sensitivity to social and cultural issues,as containers as listed under the
well as concern for modesty, is impor- Specimen subheading.
tant in providing psychological support Remove the needle and apply direct
before, during, and after the procedure. pressure with dry gauze to stop bleed-
Note that there are no food, fluid, or ing. Observe/assess venipuncture site
medication restrictions unless by for bleeding or hematoma formation and
medical direction. secure gauze with adhesive bandage.
Drugs that enhance steroid metabolism Promptly transport the specimen to the
may be withheld by medical direction laboratory for processing and analysis.
prior to metyrapone stimulation testing. The tightly capped sample should be
Instruct the patient to refrain from placed in an ice slurry immediately after
strenuous exercise for 12 hr before the collection. Information on the specimen
test and to remain in bed or at rest for label should be protected from water in
1 hr immediately before the test. Avoid the ice slurry by first placing the speci-
smoking and alcohol use. men in a protective plastic bag.
Prepare an ice slurry in a cup or plastic
bag to have on hand for immediate trans- POST-TEST:
port of the specimen to the laboratory.
Inform the patient that a report of the
INTRATEST: results will be made available to the
requesting health-care provider (HCP), who
Potential Complications: will discuss the results with the patient.
Adverse reactions to metyrapone include Recognize anxiety related to test
nausea and vomiting (N/V), abdominal results, and offer support.

Monograph_A_001-023.indd 18 17/11/14 12:03 PM


Alanine Aminotransferase 19

Observe/assess the patient who has testing, treatment, or referral to


been administered metyrapone for signs another HCP.
and symptoms of an acute adrenal Answer any questions or address any
(addisonian) crisis which may include concerns voiced by the patient or family.
abdominal pain, nausea, vomiting, Teach the patient and family the effects A
hypotension, tachycardia, tachypnia, of the disease process and associated
dehydration, excessively increased per- treatments
spiration of the face and hands, sudden
and significant fatigue or weakness, Expected Patient Outcomes:
confusion, loss of consciousness, shock, Knowledge
coma. Potential interventions include States the importance of compliance
immediate corticosteroid replacement with the recommended therapeutic
(IV or IM), airway protection and mainte- regime to health maintenance
nance, administration of dextrose for States understanding of the necessity
hypoglycemia, correction of electrolyte of altering the medication regime dur-
imbalance, and rehydration with IV fluids. ing times of illness and stress
Depending on the results of this proce- Skills
dure, additional testing may be performed Demonstrates proficiency in the self-
to evaluate or monitor progression of the administration of prescribed steroids
disease process and determine the need Adheres to the request to stand slowly
for a change in therapy. If a diagnosis of to prevent orthostatic hypotension
Cushings disease is made, pituitary com-
puted tomography (CT) or magnetic reso- Attitude
nance imaging (MRI) may be indicated Complies with the HCPs request to
prior to surgery. If a diagnosis of ectopic wear a medic alert bracelet indicating
corticotropin syndrome is made, abdomi- adrenal insufficiency and steroid use
nal CT or MRI may be indicated prior to Complies with the HCPs request to
surgery. Evaluate test results in relation to increase oral fluid intake with a diet
the patients symptoms and other tests high in sodium and low in potassium
performed. (Addisons disease)

Patient Education: RELATED MONOGRAPHS:


Instruct the patient to resume normal Related tests include cortisol and chal-
activity as directed by the HCP. lenge tests, CT abdomen, CT pituitary,
Provide contact information, if desired, for MRI abdomen, MRI pituitary, TSH,
the Cushings Support and Research thyroxine, and US abdomen.
Foundation (www.csrf.net). See the Endocrine System table at the
Reinforce information given by the end of the book for related tests by
patients HCP regarding further body system.

Alanine Aminotransferase
SYNONYM/ACRONYM: Serum glutamic pyruvic transaminase (SGPT), ALT.

COMMON USE: To assess liver function related to liver disease and/or damage.

SPECIMEN: Serum (1 mL) collected in a gold-, red-, or red/gray-top tube. Plasma


(1 mL) collected in a green-top (heparin) tube is also acceptable.

NORMAL FINDINGS: (Method: Spectrophotometry)

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20 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

indicated by gradually declining


Conventional & levels
Age SI Units
POTENTIAL DIAGNOSIS
A Newborn12 mo 1345 units/L
13 mo60 yr Increased in
Male 1040 units/L Related to release of ALT from
Female 735 units/L damaged liver, kidney, heart, pan-
6190 yr creas, red blood cells, or skeletal
Male 1340 units/L muscle cells.
Female 1028 units/L
Greater than 90 yr
Acute pancreatitis
AIDS (related to hepatitis B
Male 638 units/L
co-infection)
Female 524 units/L
Biliary tract obstruction
Values may be slightly elevated in older adults Burns (severe)
due to the effects of medications and the Chronic alcohol abuse
presence of multiple chronic or acute diseases Cirrhosis
with or without muted symptoms.
Fatty liver
Hepatic carcinoma
DESCRIPTION:Alanine aminotransfer- Hepatitis
ase (ALT), formerly known as serum Infectious mononucleosis
glutamic pyruvic transaminase Muscle injury from intramuscular
(SGPT), is an enzyme produced by injections, trauma, infection, and
the liver.The highest concentration seizures (recent)
of ALT is found in liver cells; mod- Muscular dystrophy
erate amounts are found in kidney Myocardial infarction
cells; and smaller amounts are found Myositis
in heart, pancreas, spleen, skeletal Pancreatitis
muscle, and red blood cells. When Pre-eclampsia
liver damage occurs, serum levels Shock (severe)
of ALT may increase as much as Decreased in
50 times normal, making this a Pyridoxal phosphate deficiency
sensitive test for evaluating liver (related to a deficiency of pyri-
function. ALT is part of a group of doxal phosphate that results in
tests known as LFTs or liver func- decreased production of ALT)
tion tests used to evaluate liver
function: ALT, Albumin, Alkaline CRITICAL FINDINGS: N/A
phosphatase, Aspartate amino-
transferase (AST), Bilirubin, direct, INTERFERING FACTORS
Bilirubin, total, and Protein, total Drugs that may increase ALT levels
by causing cholestasis include ana-
This procedure is bolic steroids, dapsone, estrogens,
contraindicated for: N/A ethionamide, icterogenin, mepazine,
methandriol, oral contraceptives,
INDICATIONS oxymetholone, propoxyphene,
Compare serially with aspartate sulfonylureas, and zidovudine.
aminotransferase (AST) levels to Drugs that may increase ALT levels
track the course of liver disease by causing hepatocellular damage
Monitor liver damage resulting include acetaminophen (toxic), ace-
from hepatotoxic drugs tylsalicylic acid, anticonvulsants,
Monitor response to treatment of asparaginase, carbutamide, cephalo-
liver disease, with tissue repair sporins, chloramphenicol, clofibrate,

Monograph_A_001-023.indd 20 17/11/14 12:03 PM


Alanine Aminotransferase 21

cytarabine, danazol, dinitrophenol, methyldopa, methylthiouracil,


enflurane, erythromycin, ethambutol, naproxen, nitrofurans, oral contra-
ethionamide, ethotoin, florantyrone, ceptives, probenecid, procainamide,
foscarnet, gentamicin, gold salts, and tetracyclines. A
halothane, ibufenac, indomethacin, Drugs that may decrease ALT levels
interleukin-2, isoniazid, lincomycin, include cyclosporine, interferons,
low-molecular-weight heparin, meta- metronidazole (affects enzymatic
hexamide, metaxalone, methoxsalen, test methods), and ursodiol.

NURSING IMPLICATIONS AND PROCEDURE


Potential Nursing Problems:

Problem Signs & Symptoms Interventions


Pain (Related to Emotional symptoms of Collaborate with the patient
organ inflam distress; crying; and physician to identify the
mation and agitation; facial grimace; best pain management
surrounding moaning; verbalization of modality to provide relief;
tissues; pain; rocking motions; refrain from activities that
excessive irritability; disturbed may aggravate pain; use the
alcohol sleep; diaphoresis; application of heat or cold to
intake; altered blood pressure the best effect in managing
infection) and heart rate; nausea; pain; monitor pain severity
vomiting; self-report of
pain; upper abdominal
and gastric pain after
eating fatty foods or
alcohol intake with acute
pancreatic disease; pain,
which may be decreased
or absent in chronic
pancreatic disease
Fluid volume Overload: Edema, Complete a daily weight with
(Related to shortness of breath, monitoring of trends;
vomiting; increased weight, accurate intake and output;
decreased ascites, rales, rhonchi, collaborate with physician
intake; and diluted laboratory with administration of IV
compromised values. Deficient: fluids to support hydration;
renal function; decreased urinary monitor laboratory values
overly output, fatigue, and that reflect alterations in fluid
aggressive fluid sunken eyes, dark status (potassium, blood
resuscitation; urine, decreased blood urea nitrogen, creatinine,
overly pressure, increased calcium, hemoglobin, and
aggressive heart rate, and altered hematocrit); manage
diuresis) mental status underlying cause of fluid
alteration; monitor urine
characteristics and respiratory
status; establish baseline
assessment data; collaborate
(table continues on page 22)
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22 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

NURSING IMPLICATIONS AND PROCEDURE


Problem Signs & Symptoms Interventions
with physician to adjust oral
A and intravenous fluids to
provide optimal hydration
status; administer replacement
electrolytes, as ordered
Nutrition Increased liver function Administer enteral nutrition;
(Related to tests; hyperglycemia administer parenteral
metabolic with polyuria, weight nutrition; monitor laboratory
imbalances) loss, weakness, values and collaborate with
nausea, vomiting; physician on replacement
hypocalcemia with strategies; correlate
confusion, intestinal laboratory values with IV fluid
cramping, diarrhea; infusion and collaborate with
hypertriglyceridemia; the physician and pharmacist
altered thiamine with to adjust to patient needs;
weakness, confusion ensure adequate pain
control; monitor vital sings for
alterations associated
metabolic imbalances
Gastrointestinal Nausea; vomiting; Perform nasogastric intubation
problems abdominal distention; (NGT) to remove gastric
(Related to unexplained weight secretions and decrease
altered motility; loss; steatorrhea; pancreatic secretions which
irritation of the diarrhea; visible may result in autodigestion;
GI tract; taste abdominal distention; monitor NGT for patency and
alterations; ascites; diminished or amount of drainage; assess
pancreatic and absent bowel sounds hydration status; assess bowel
gastric sounds frequently; measure
secretions) abdominal girth to monitor
degree of abdominal distention

PRETEST: Review the procedure with the patient.


Positively identify the patient using at Inform the patient that specimen collec-
least two unique identifiers before pro- tion takes approximately 5 to 10 min.
viding care, treatment, or services. Address concerns about pain and
Patient Teaching: Inform the patient this explain that there may be some dis-
test can assist with evaluation of liver comfort during the venipuncture.
function and help identify disease. Sensitivity to social and cultural issues,
Obtain a history of the patients com- as well as concern for modesty, is impor-
plaints, including a list of known allergens, tant in providing psychological support
especially allergies or sensitivities to latex. before, during, and after the procedure.
Obtain a history of the patients hepa- Note that there are no food, fluid, or
tobiliary system, symptoms, and medication restrictions unless by medi-
results of previously performed labora- cal direction.
tory tests and diagnostic and surgical INTRATEST:
procedures.
Potential Complications: N/A
Obtain a list of the patients current
medications including herbs, nutritional Avoid the use of equipment containing
supplements, and nutraceuticals (see latex if the patient has a history of
Appendix H online at DavisPlus). allergic reaction to latex.

Monograph_A_001-023.indd 22 17/11/14 12:03 PM


Alanine Aminotransferase 23

Instruct the patient to cooperate fully Patient Education:


and to follow directions. Direct the Reinforce information given by the
patient to breathe normally and to patients HCP regarding further testing,
avoid unnecessary movement. treatment, or referral to another HCP.
Observe standard precautions, and fol- A
Recognize anxiety related to test results,
low the general guidelines in Appendix A. and answer any questions or address any
Positively identify the patient, and label concerns voiced by the patient or family.
the appropriate specimen container Provide teaching and information
with the corresponding patient regarding the clinical implications of the
demographics, initials of the person test results, as appropriate.
collecting the specimen, date, and time Educate the patient regarding access
of collection. Perform a venipuncture. to counseling services. Provide contact
Remove the needle, and apply direct information, if desired, for the Centers
pressure with dry gauze to stop bleeding. for Disease Control and Prevention
Observe/assess venipuncture site for (www.cdc.gov/diseasesconditions).
bleeding and hematoma formation and Provide information regarding disease
secure gauze with adhesive bandage. process and proactive activities that the
Promptly transport the specimen to the patient can take in managing health.
laboratory for processing and analysis. Provide samples of dietary selections
POST-TEST:
that can support pancreatic and
liver health and that are culturally
Inform the patient that a report of the appropriate.
results will be made available to the
requesting health-care provider (HCP), who Expected Patient Outcomes:
will discuss the results with the patient. Knowledge
Nutritional Considerations: Increased ALT The patient and family verbalize
levels may be associated with liver dis- understanding of causative factors of
ease. Dietary recommendations may be pancreatitis and liver disease.
indicated and vary depending on the The patient and family verbalize under-
severity of the condition. A low-protein standing that the disease can reoccur
diet may be in order if the patients liver if not adhering to positive actions to
has lost the ability to process the end change lifestyle.
products of protein metabolism. A diet of
Skills
soft foods may be required if esophageal
The patient creates a diet plan that
varices have developed. Ammonia levels
supports liver and pancreatic health.
may be used to determine whether pro-
The patient takes medication as pre-
tein should be added to or reduced from
scribed to limit pancreatic secretions
the diet. Patients should be encouraged
and decrease pain.
to eat simple carbohydrates and emulsi-
fied fats (as in homogenized milk or Attitude
eggs) rather than complex carbohy- The patient agrees to seek counseling
drates (e.g., starch, fiber, and glycogen for alcohol abstinence.
[animal carbohydrates]) and complex The patient agrees to control potential
fats, which require additional bile to behaviors that could trigger future
emulsify them so that they can be used. disease episodes.
The cirrhotic patient should be carefully
observed for the development of ascites, RELATED MONOGRAPHS:
in which case fluid and electrolyte bal- Related tests include acetaminophen,
ance requires strict attention. ammonia, AST, bilirubin, biopsy liver,
Depending on the results of this proce- cholangiography percutaneous transhe-
dure, additional testing may be performed patic, electrolytes, GGT, hepatitis anti-
to evaluate or monitor progression of the gens and antibodies, LDH, liver and
disease process and determine the need spleen scan, US abdomen, and US liver.
for a change in therapy. Evaluate test See the Hepatobiliary System table at
results in relation to the patients symp- the end of the book for related tests by
toms and other tests performed. body system.

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24 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

Albumin and Albumin/Globulin Ratio


A
SYNONYM/ACRONYM: Alb, A/G ratio.

COMMON USE: To assess liver or kidney function and nutritional status.

SPECIMEN: Serum (1 mL) collected in a gold-, red-, or red/gray-top tube. Plasma


(1 mL) collected in a green-top (heparin) tube is also acceptable.

NORMAL FINDINGS: (Method: Spectrophotometry) Normally the albumin/globulin


(A/G) ratio is greater than 1.

Age Conventional Units SI Units (Conventional Units 10)


Cord 2.84.3 g/dL 2843 g/L
Newborn7 d 2.63.6 g/dL 2636 g/L
830 d 24.5 g/dL 2045 g/L
13 mo 24.8 g/dL 2048 g/L
46 mo 2.14.9 g/dL 2149 g/L
712 mo 2.14.7 g/dL 2147 g/L
13 yr 3.44.2 g/dL 3442 g/L
46 yr 3.55.2 g/dL 3552 g/L
719 yr 3.75.6 g/dL 3756 g/L
2040 yr 3.75.1 g/dL 3751 g/L
4160 yr 3.44.8 g/dL 3448 g/L
6190 yr 3.24.6 g/dL 3246 g/L
Greater than 90 yr 2.94.5 g/dL 2945 g/L

DESCRIPTION: Most of the bodys an indicator of chronic deficiency


total protein is a combination of than of short-term deficiency.
albumin and globulins. Albumin, the Hypoalbuminemia or low serum
protein present in the highest con- albumin, a level less than 3.4 g/dL,
centrations, is the main transport can stem from many causes and
protein in the body for hormones, may be a useful predictor of mortal-
therapeutic drugs, calcium, magne- ity. Normally albumin is not excret-
sium, heme, and waste products ed in urine. However, in cases of
such as bilirubin. Albumin also sig- kidney damage some albumin may
nificantly affects plasma oncotic be lost due to decreased kidney
pressure, which regulates the distri- function as seen in nephrotic syn-
bution of body fluid between blood drome, and in pregnant women
vessels, tissues, and cells. Albumin is with pre-eclampsia and eclampsia.
synthesized in the liver. Low levels Albumin levels are affected by
of albumin may be the result of posture. Results from specimens
either inadequate intake, inade- collected in an upright posture are
quate production, or excessive loss. higher than results from specimens
Albumin levels are more useful as collected in a supine position.

Monograph_A_024-046.indd 24 17/11/14 12:03 PM


Albumin and Albumin/Globulin Ratio 25

Decreased synthesis by the liver:


The albumin/globulin (A/G) Acute and chronic liver disease
ratio is useful in the evaluation of (e.g., alcoholism, cirrhosis, hepatitis)
liver and kidney disease. The ratio
is calculated using the following
(evidenced by a decrease in normal
A
liver function; the liver is the bodys
formula: site of protein synthesis)
Genetic analbuminemia (related to genetic
albumin/(total protein albumin) inability of liver to synthesize albumin)
Inflammation and chronic dis-
where globulin is the difference eases result in production of
between the total protein value acute-phase reactant and other
and the albumin value. For exam- globulin proteins; the increase in
ple, with a total protein of 7 g/dL globulins causes a corresponding
and albumin of 4 g/dL, the A/G relative decrease in albumin:
ratio is calculated as 4/(7 4) or Amyloidosis
4/3 = 1.33. A reversal in the ratio, Bacterial infections
where globulin exceeds albumin Monoclonal gammopathies (e.g.,
(i.e., ratio less than 1.0), is clini- multiple myeloma, Waldenstrms
cally significant. macroglobulinemia)
Neoplasm
Parasitic infestations
This procedure is
Peptic ulcer
contraindicated for: N/A Prolonged immobilization
Rheumatic diseases
INDICATIONS Severe skin disease
Assess nutritional status of hospital- Increased loss over body surface:
ized patients, especially geriatric Burns (evidenced by loss of interstitial
patients fluid albumin)
Evaluate chronic illness Enteropathies (e.g., gluten sensitivity,
Evaluate liver disease Crohns disease, ulcerative colitis,
Whipples disease) (evidenced by
POTENTIAL DIAGNOSIS sensitivity to ingested substances
Increased in or related to inadequate absorption
from intestinal loss)
Any condition that results in a
Fistula (gastrointestinal or lymphatic)
decrease of plasma water (e.g., dehy-
(related to loss of sequestered albumin
dration); look for increase in hemo-
from general circulation)
globin and hematocrit. Decreases in Hemorrhage (related to fluid loss)
the volume of intravascular liquid Kidney disease (related to loss from
automatically result in concentration damaged renal tubules)
of the components present in the Pre-eclampsia (evidenced by excessive
remaining liquid, as reflected by an renal loss)
elevated albumin level. Rapid hydration or overhydration
Hyperinfusion of albumin (evidenced by dilution effect)
Repeated thoracentesis or paracentesis
Decreased in (related to removal of albumin in
Insufficient intake: accumulated third-space fluid)
Malabsorption (related to lack of Increased catabolism:
amino acids available for protein Cushings disease (related to excessive
synthesis) cortisol induced protein metabolism)
Malnutrition (related to insufficient Thyroid dysfunction (related to
dietary source of amino acids required overproduction of albumin binding
for protein synthesis) thyroid hormones)

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26 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

Increased blood volume Obtain a list of the patients current


(hypervolemia): medications including herbs, nutritional
Congestive heart failure (evidenced by supplements, and nutraceuticals (see
Appendix H online at DavisPlus).
A dilution effect)
Review the procedure with the patient.
Pre-eclampsia (related to fluid retention)
Pregnancy (evidenced by increased Inform the patient that specimen col-
circulatory volume from placenta
lection takes approximately 5 to 10 min.
Address concerns about pain and
and fetus)
explain that there may be some dis-
comfort during the venipuncture.
CRITICAL FINDINGS: N/A Sensitivity to social and cultural issues,
as well as concern for modesty, is impor-
INTERFERING FACTORS tant in providing psychological support
Drugs that may increase albumin before, during, and after the procedure.
levels include carbamazepine, Note that there are no food, fluid,
furosemide, phenobarbital, and or medication restrictions unless by
prednisolone. medical direction.
Drugs that may decrease albumin INTRATEST:
levels include acetaminophen (poi-
Potential Complications: N/A
soning), amiodarone, asparaginase,
dextran, estrogens, ibuprofen, inter- Avoid the use of equipment containing
latex if the patient has a history of aller-
leukin-2, methotrexate, methyldopa,
gic reaction to latex.
niacin, nitrofurantoin, oral contra- Instruct the patient to cooperate fully
ceptives, phenytoin, prednisone, and to follow directions. Direct the
and valproic acid. patient to breathe normally and to
Availability of administered drugs avoid unnecessary movement.
is affected by variations in albumin Observe standard precautions, and fol-
levels. low the general guidelines in Appendix
A. Positively identify the patient, and
label the appropriate specimen con-
tainer with the corresponding patient
demographics, initials of the person
NURSING IMPLICATIONS collecting the specimen, date, and time
AND PROCEDURE of collection. Perform a venipuncture.
Remove the needle and apply direct
PRETEST: pressure with dry gauze to stop bleed-
Positively identify the patient using at ing. Observe/assess venipuncture site
least two unique identifiers before pro- for bleeding or hematoma formation and
viding care, treatment, or services. secure gauze with adhesive bandage.
Patient Teaching: Inform the patient this Promptly transport the specimen to the
test can assist with evaluation of liver laboratory for processing and analysis.
and kidney function, as well as chronic
disease. POST-TEST:
Obtain a history of the patients com- Inform the patient that a report of the
plaints, including a list of known aller- results will be made available to the
gens, especially allergies or sensitivities requesting health-care provider (HCP),
to latex. The patient should be who will discuss the results with the
assessed for signs of edema or ascites. patient.
Obtain a history of the patients gastro- Nutritional Considerations: Dietary recom-
intestinal, genitourinary, and hepatobili- mendations may be indicated and will
ary systems; symptoms; and results of vary depending on the severity of the
previously performed laboratory tests condition. Ammonia levels may be
and diagnostic and surgical procedures. used to determine whether protein

Monograph_A_024-046.indd 26 17/11/14 12:03 PM


Aldolase 27

should be added to or reduced from order to prevent development of toxic


the diet. drug concentrations. Evaluate test
Reinforce information given by the results in relation to the patients symp-
patients HCP regarding further testing, toms and other tests performed.
treatment, or referral to another HCP. A
Recognize anxiety related to test RELATED MONOGRAPHS:
results and answer any questions or Related tests include ALT, ALP, ammonia,
address any concerns voiced by the antismooth muscle antibodies, AST,
patient or family. bilirubin, biopsy liver, CBC hematocrit,
Depending on the results of this CBC hemoglobin, CT biliary tract and
procedure, additional testing may be liver, GGT, hepatitis antibodies and anti-
performed to evaluate or monitor pro- gens, KUB studies, laparoscopy abdom-
gression of the disease process and inal, liver scan, MRI abdomen, osmolality,
determine the need for a change in ther- potassium, prealbumin, protein total and
apy. Availability of administered drugs fractions, radiofrequency ablation liver,
is affected by variations in albumin lev- sodium, US abdomen, and US liver.
els. Patients receiving therapeutic drug See the Gastrointestinal, Genitourinary,
treatments should have their drug levels and Hepatobiliary systems tables at
monitored when levels of the transport the end of the book for related tests by
protein, albumin, are decreased in body system.

Aldolase
SYNONYM/ACRONYM: ALD.

COMMON USE: To assist in the diagnosis of muscle-wasting diseases such as


muscular dystrophy or other diseases that cause muscle and cellular damage
such as hepatitis and cirrhosis of the liver.

SPECIMEN: Serum (1 mL) collected in a gold-, red-, or red/gray-top tube.

NORMAL FINDINGS: (Method: Spectrophotometry)

POTENTIAL DIAGNOSIS
Conventional &
Age SI Units Increased in
ALD is released from any damaged
Newborn30 d 632 units/L
cell in which it is stored, so diseases
1 mo2 yr 3.411.8 units/L
of skeletal muscle, cardiac muscle,
36 yr 2.78.8 units/L
pancreas, red blood cells, and liver
717 yr 3.39.7 units/L
that cause cellular destruction
Adult Less than demonstrate elevated ALD levels.
8.1 units/L
Carcinoma (lung, breast, and genito-
urinary tract and metastasis to liver)
This procedure is Dermatomyositis
contraindicated for: N/A Duchennes muscular dystrophy

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28 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

Hepatitis (acute viral or toxic) Decreased in


Limb girdle muscular dystrophy Hereditary fructose intolerance
Myocardial infarction (evidenced by hereditary defi-
A Pancreatitis (acute) ciency of the aldolase B enzyme)
Polymyositis Late stages of muscle-wasting
Severe crush injuries diseases in which muscle mass
Tetanus has significantly diminished
Trichinosis (related to
myositis) CRITICAL FINDINGS: N/A
Find and print out the full monograph at DavisPlus (http://davisplus.fadavis
.com, keyword Van Leeuwen).

Aldosterone
SYNONYM/ACRONYM: N/A.

COMMON USE: To assist in the diagnosis of primary hyperaldosteronism disor-


ders such as Conns syndrome and Addisons disease. Blood levels fluctuate
with dehydration and fluid overload. This test can be used in evaluation of
hypertension.

SPECIMEN: Serum (1 mL) collected in a gold-, red-, or red/gray-top tube. Plasma


(1 mL) collected in a green-top (heparin) or lavender-top (EDTA) tube is also
acceptable.

NORMAL FINDINGS: (Method: Radioimmunoassay)

Age Conventional Units SI Units (Conventional Units 0.0277)


Cord blood 40200 ng/dL 1.115.54 nmol/L
3 days1 wk 7184 ng/dL 0.195.09 nmol/L
1 mo1 yr 590 ng/dL 0.142.49 nmol/L
1323 mo 754 ng/dL 0.191.49 nmol/L
210 yr
Supine 335 ng/dL 0.080.97 nmol/L
Upright 580 ng/dL 0.142.22 nmol/L
1115 yr
Supine 222 ng/dL 0.060.61 nmol/L
Upright 448 ng/dL 0.111.33 nmol/L
Adult
Supine 316 ng/dL 0.080.44 nmol/L
Upright 730 ng/dL 0.190.83 nmol/L
Older Adult Levels decline
with age
These values reflect a normal-sodium diet. Values for a low-sodium diet are three to five times higher.

Monograph_A_024-046.indd 28 17/11/14 12:03 PM


Aldosterone 29

DESCRIPTION: Aldosterone is a with a sodium-loading protocol.


mineralocorticoid secreted by the A captopril protocol can be sub-
zona glomerulosa of the adrenal stituted for patients who may
cortex and is regulated by the not tolerate the sodium-loading
A
renin-angiotensin system. Changes protocol.
in renal blood flow trigger or sup-
press release of renin from the This procedure is
glomeruli. The presence of circu- contraindicated for: N/A
lating renin stimulates the liver to
produce angiotensin I. Angiotensin INDICATIONS
I is converted by the lung and Evaluate hypertension of unknown
kidneys into angiotensin II, a cause, especially with hypokalemia
potent trigger for the release of not induced by diuretics
aldosterone. Aldosterone and the Investigate suspected hyperaldoste-
renin-angiotensin system work ronism, as indicated by elevated levels
together to regulate sodium and Investigate suspected hypoaldosteron-
potassium levels. Aldosterone acts ism, as indicated by decreased levels
to increase sodium reabsorption
in the renal tubules. This results in POTENTIAL DIAGNOSIS
excretion of potassium, increased
water retention, increased blood Increased in
volume, and increased blood pres-
sure. This test is of little diagnostic Increased With Decreased Renin
value in differentiating primary Levels
and secondary aldosteronism Primary hyperaldosteronism
unless plasma renin activity is (evidenced by overproduction
measured simultaneously (see related to abnormal adrenal
monograph titled Renin). A vari- gland function):
ety of factors influence serum Adenomas (Conns syndrome)
aldosterone levels, including sodi- Bilateral hyperplasia of the
um intake, certain medications, aldosterone-secreting zona
and activity. Secretion of aldoste- glomerulosa cells
rone is also affected by ACTH, a
pituitary hormone that primarily Increased With Increased Renin
stimulates secretion of glucocorti- Levels
coids and minimally affects secre-
tion of mineralocorticosteroids. Secondary hyperaldosteronism
Patients with serum potassium (related to conditions that
less than 3.6 mEq/L and 24-hour increase renin levels, which then
urine potassium greater than 40 stimulate aldosterone secretion):
mEq/L fit the general criteria to Bartters syndrome (related to
test for aldosteronism. Renin is excessive loss of potassium by
low in primary aldosteronism and the kidneys, leading to release of
high in secondary aldosteronism. renin and subsequent release of
A ratio of plasma aldosterone to aldosterone)
plasma renin activity greater than Cardiac failure (related to diluted
50 is significant. Ratios greater concentration of sodium by
than 20 obtained after unchal- increased blood volume)
lenged screening may indicate Chronic obstructive pulmonary
the need for further evaluation disease
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30 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

Cirrhosis with ascites formation Excess secretion of deoxycortico-


(related to diluted concentration sterone (related to suppression
of sodium by increased blood of ACTH production by cortisol,
A volume) which in turn affects aldosterone
Diuretic abuse (related to direct secretion)
stimulation of aldosterone Turners syndrome (25% of cases)
secretion) (related to congenital adrenal
Hypovolemia (secondary to hem- hyperplasia resulting in under-
orrhage and transudation) production of aldosterone and
Laxative abuse (related to direct overproduction of androgens)
stimulation of aldosterone
secretion) CRITICAL FINDINGS: N/A
Nephrotic syndrome (related to
excessive renal protein loss,
INTERFERING FACTORS
development of decreased
Drugs that may increase aldoste-
oncotic pressure, fluid reten-
rone levels include amiloride,
tion, and diluted concentration
ammonium chloride, angiotensin,
of sodium)
angiotensin II, dobutamine, dopa-
Starvation (after 10 days) (related
mine, endralazine, fenoldopam,
to diluted concentration of sodium
hydralazine, hydrochlorothiazide,
by development of edema)
laxatives (abuse), metoclopramide,
Thermal stress (related to direct
nifedipine, opiates, potassium, spi-
stimulation of aldosterone
ronolactone, and zacopride.
secretion)
Drugs that may decrease aldoste-
Toxemia of pregnancy (related to
rone levels include atenolol, capto-
diluted concentration of sodium
pril, carvedilol, cilazapril, enalapril,
by increased blood volume evi-
fadrozole, glycyrrhiza (licorice),
denced by edema; placental
ibopamine, indomethacin, lisino-
corticotropin-releasing hormone
pril, nicardipine, NSAIDs, perindo-
stimulates production of mater-
pril, ranitidine, saline, sinorphan,
nal adrenal hormones that can
and verapamil. Prolonged heparin
also contribute to edema)
therapy also decreases aldosterone
levels.
Decreased in Upright body posture, stress, strenu-
Without Hypertension
ous exercise, and late pregnancy
Addisons disease (related to lack can lead to increased levels.
of function in the adrenal cortex) Recent radioactive scans or radiation
Hypoaldosteronism (secondary to within 1 wk before the test can inter-
renin deficiency) fere with test results when radioim-
Isolated aldosterone deficiency munoassay is the test method.
Diet can significantly affect results.
With Hypertension A low-sodium diet can increase
Acute alcohol intoxication (related serum aldosterone, whereas a high-
to toxic effects of alcohol on sodium diet can decrease levels.
adrenal gland function and there- Decreased serum sodium and ele-
fore secretion of aldosterone) vated serum potassium increase
Diabetes (related to impaired aldosterone secretion. Elevated
conversion of prerenin to renin serum sodium and decreased
by damaged kidneys, resulting in serum potassium suppress aldoste-
decreased aldosterone) rone secretion.

Monograph_A_024-046.indd 30 17/11/14 12:03 PM


Aldosterone 31

NURSING IMPLICATIONS AND PROCEDURE


Potential Nursing Problems:
A
Problem Signs & Symptoms Interventions
Fluid volume Deficient: Monitor intake and output; assess
(Related to hypotension; for symptoms of dehydration
hypovolemia decreased cardiac (dry skin, dry mucous
associated output; decreased membranes, poor skin turgor,
with adrenal urinary output; dry sunken eyeballs), monitor and
insufficiency; skin/mucous trend vital signs; monitor for
cortisol membranes; poor symptoms of poor cardiac
insufficiency; skin turgor; sunken output (rapid, weak, thready
hyponatremia, eyeballs; increased pulse); monitor daily weight with
vomiting, urine specific monitoring of trends; collaborate
diarrhea) gravity; with physician with
hemoconcentration; administration of IV fluids to
weakness, lethargy, support hydration; monitor
dizziness, laboratory values that reflect
tachycardia, low alterations in fluid status
sodium, elevated (potassium, blood urea nitrogen,
potassium, creatinine, calcium, hemoglobin,
hypoglycemia and hematocrit, sodium);
manage underlying cause of
fluid alteration; monitor urine
characteristics and respiratory
status; establish baseline
assessment data; collaborate
with physician to adjust oral and
IV fluids to provide optimal
hydration status; administer
replacement electrolytes, as
ordered; adjust diuretics, as
appropriate, monitor and trend
blood glucose
Tissue Hypotension; Monitor blood pressure; assess
perfusion dizziness; cool for dizziness; assess extremities
(Related to extremities; pallor; for skin temperature, color,
inadequate capillary refill warmth; assess capillary refill;
fluid volume; greater than 3 sec assess pedal pulses; monitor
decreased in fingers and toes; for numbness, tingling,
cortisol weak pedal pulses; hyperesthesia, hypoesthesia;
levels) altered level of monitor for DVT; carefully use
consciousness; heat and cold on affected areas;
altered sensation; use foot cradle to keep pressure
urinary output less off of affected body parts;
than 30 mL/hr provide oxygen as required

(table continues on page 32)

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32 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

Problem Signs & Symptoms Interventions


Self-care Difficulty fastening Reinforce self-care techniques as
A (Related to clothing; difficulty taught by occupational therapy;
dizziness, performing personal ensure that the patient has
fatigue, hygiene; inability to adequate time to perform self-
weakness, maintain appropriate care; encourage use of assistive
vomiting, appearance; devices to maintain
diarrhea, difficulty with independence; ask if there is
anorexia) independent mobility any interference with lifestyle
activities; assess the ability to
engage in activities of daily living
Mobility Weakness, muscle Provide assistance with mobility
(Related to wasting, pain in with encouraged use of assistive
dizziness, muscles and joints, devices; assess emotional
fatigue, decreased response to limited mobility;
weakness endurance, activity assess willingness to participate
secondary to intolerance, difficult in activity; assess environment
adrenal purposeful of safety concerns; assess the
insufficiency movement, ability to engage in activities of
and reluctance to daily living; encourage early
decreased attempt to engage mobility to retain as much
cortisol in activity independent function as
levels) possible; allow sufficient time to
perform tasks without being
rushed; assess nutritional intake

PRETEST: Obtain a list of the patients current


Positively identify the patient using at medications, including herbs, nutri-
least two unique identifiers before tional supplements, and nutraceuticals
providing care, treatment, or services. (see Appendix H online at DavisPlus).
Patient Teaching: Inform the patient this Review the procedure with the patient.
test evaluates dehydration and can assist Inform the patient that specimen collec-
in identification of the causes of muscle tion takes approximately 5 to 10 min.
weakness or high blood pressure. Inform the patient that multiple speci-
Obtain a history of the patients com- mens may be required. Address con-
plaints, including a list of known aller- cerns about pain and explain that there
gens, especially allergies or sensitivities may be some discomfort during the
to latex. venipuncture. Aldosterone levels may
Obtain a history of known or sus- also be collected directly from the left
pected fluid or electrolyte imbalance, and right adrenal veins. This procedure
hypertension, renal function, or stage is performed by a radiologist via cathe-
of pregnancy. Note the amount of terization and takes approximately 1 hr.
sodium ingested in the diet over the Sensitivity to social and cultural issues,
past 2 wk. as well as concern for modesty, is
Obtain a history of the patients important in providing psychological
endocrine and genitourinary systems, support before, during, and after the
symptoms, and results of previously procedure.
performed laboratory tests and diag- Inform the patient that the required
nostic and surgical procedures. position, supine/lying down or upright/
Note any recent procedures that can sitting up, must be maintained for 2 hr
interfere with test results. before specimen collection.

Monograph_A_024-046.indd 32 17/11/14 12:03 PM


Aldosterone 33

Prescribe the patient a normal-sodium site for bleeding or hematoma


diet (1 to 2 g of sodium per day) 2 to formation and secure gauze with
4 wk before the test. Protocols may adhesive bandage.
vary among facilities. Promptly transport the specimen on
Under medical direction, the patient ice to the laboratory for processing A
should avoid diuretics, antihypertensive and analysis.
drugs and herbals, and cyclic proges-
togens and estrogens for 2 to 4 wk POST-TEST:
before the test. The patient should also Inform the patient that a report of the
be advised to avoid consuming any- results will be made available to the
thing that contains licorice for 2 wk requesting health-care provider (HCP),
before the test. Licorice inhibits short- who will discuss the results with the
chain dehydrogenase/reductase patient.
enzymes. These enzymes normally Instruct the patient to resume usual
prevent cortisol from binding to aldo- diet, medication, and activity as
sterone receptor sites in the kidney. In directed by the HCP.
the absence of these enzymes, cortisol Instruct the patient to notify the HCP of
acts on the kidney and triggers the any signs and symptoms of dehydra-
same effects as aldosterone, which tion or fluid overload related to elevated
include increased potassium excretion, aldosterone levels or compromised
sodium retention, and water retention. sodium regulatory mechanisms.
Aldosterone levels are not affected by Nutritional Considerations: Aldosterone
licorice ingestion, but the simultaneous levels are involved in the regulation of
measurements of electrolytes may pro- body fluid volume. Educate patients
vide misleading results. about the importance of proper water
INTRATEST: balance. Tap water may also contain
other nutrients. Water-softening sys-
Potential Complications: N/A tems replace minerals (e.g., calcium,
Ensure that the patient has complied magnesium, iron) with sodium, so cau-
with dietary, medication, and pretesting tion should be used if a low-sodium
preparations regarding activity. diet is prescribed.
Avoid the use of equipment containing Nutritional Considerations: Because aldo-
latex if the patient has a history of sterone levels affect sodium levels,
allergic reaction to latex. some consideration may be given to
Instruct the patient to cooperate fully dietary adjustment if sodium allow-
and to follow directions. Direct the ances need to be regulated. Educate
patient to breathe normally and to patients with low sodium levels that the
avoid unnecessary movement. major source of dietary sodium is table
Observe standard precautions, and fol- salt. Many foods, such as milk and
low the general guidelines in Appendix A. other dairy products, are also good
Positively identify the patient, and label sources of dietary sodium. Most other
the appropriate tubes with the corre- dietary sodium is available through
sponding patient demographics, date, consumption of processed foods.
time of collection, patient position Patients who need to follow low-
(upright or supine), and exact source of sodium diets should avoid beverages
specimen (peripheral versus arterial). such as colas, ginger ale, Gatorade,
Perform a venipuncture after the patient lemon-lime sodas, and root beer. Many
has been in the upright (sitting or over-the-counter medications, includ-
standing) position for 2 hr. If a supine ing antacids, laxatives, analgesics,
specimen is requested on an inpatient, sedatives, and antitussives, contain
the specimen should be collected early significant amounts of sodium. The
in the morning before rising. best advice is to emphasize the impor-
Remove the needle, and apply direct tance of reading all food, beverage,
pressure with dry gauze to stop and medicine labels. Potassium is
bleeding. Observe/assess venipuncture present in all plant and animal cells,

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34 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

making dietary replacement simple. States understanding that medication


An HCP or nutritionist should be con- will need to be taken continuously for
sulted before considering the use of the rest of their lives
salt substitutes.
A Depending on the results of this Skills
Identifies diet selections that are lower
procedure, additional testing may
in potassium and higher in sodium and
be performed to evaluate or monitor
protein
progression of the disease process
Performs and accurately records
and determine the need for a change
weight daily
in therapy. Evaluate test results in
relation to the patients symptoms Attitude
and other tests performed. Adheres to medication regime with the
understanding that sudden cessation
Patient Education:
is dangerous
Reinforce information given by the Complies with the request to report
patients HCP regarding further infections, or stressors, to HCP for
testing, treatment, or referral to medication adjustments
another HCP.
Answer any questions or address any RELATED MONOGRAPHS:
concerns voiced by the patient and/or Related tests include adrenal
family. gland scan, biopsy kidney, BUN,
Teach the patient to report any gastric catecholamines, cortisol, creatinine,
distress or dark stools associated with glucose, magnesium, osmolality,
prescribed medication use. potassium, protein urine, renin,
Expected Patient Outcomes: sodium, and UA.
See the Endocrine and Genitourinary
Knowledge systems tables at the end of the
States the importance of taking pre- book for related tests by body
scribed medication regularly system.

Alkaline Phosphatase and Isoenzymes


SYNONYM/ACRONYM: Alk Phos, ALP and fractionation, heat-stabile ALP.

COMMON USE: To assist in the diagnosis of liver cancer and cirrhosis, or bone
cancer and bone fracture.

SPECIMEN: Serum (1 mL) collected in a gold-, red-, or red/gray-top tube. Plasma


(1 mL) collected in a green-top (heparin) tube is also acceptable.

NORMAL FINDINGS: (Method: Spectrophotometry for total alkaline phosphatase,


inhibition/electrophoresis for fractionation)

Monograph_A_024-046.indd 34 17/11/14 12:03 PM


Alkaline Phosphatase and Isoenzymes 35

Conventional & Bone


Total ALP SI Units Fraction Liver Fraction
030 d A
Male 75375 units/L
Female 65350 units/L
111 mo
Male 70350 units/L
Female 80330 units/L
15 yr
Male 56350 units/L 39308 units/L Less than 8101 units/L
Female 73378 units/L 56300 units/L Less than 853 units/L
67 yr
Male 70364 units/L 50319 units/L Less than 876 units/L
Female 73378 units/L 56300 units/L Less than 853 units/L
8 yr
Male 70364 units/L 50258 units/L Less than 862 units/L
Female 98448 units/L 78353 units/L Less than 862 units/L
912 yr
Male 112476 units/L 78339 units/L Less than 881 units/L
Female 98448 units/L 78353 units/L Less than 862 units/L
13 yr
Male 112476 units/L 78389 units/L Less than 848 units/L
Female 56350 units/L 28252 units/L Less than 850 units/L
14 yr
Male 112476 units/L 78389 units/L Less than 848 units/L
Female 56266 units/L 31190 units/L Less than 848 units/L
15 yr
Male 70378 units/L 48311 units/L Less than 839 units/L
Female 42168 units/L 20115 units/L Less than 853 units/L
16 yr
Male 70378 units/L 48311 units/L Less than 839 units/L
Female 28126 units/L 1487 units/L Less than 850 units/L
17 yr
Male 56238 units/L 34190 units/L Less than 839 units/L
Female 28126 units/L 1784 units/L Less than 853 units/L
18 yr
Male 56182 units/L 34146 units/L Less than 839 units/L
Female 28126 units/L 1784 units/L Less than 853 units/L
19 yr
Male 42154 units/L 25123 units/L Less than 839 units/L
Female 28126 units/L 1784 units/L Less than 853 units/L
20 yr
Male 45138 units/L 2573 units/L Less than 848 units/L
Female 33118 units/L 1756 units/L Less than 850 units/L
21 yr and older
Male 35142 units/L 1173 units/L 093 units/L
Female 25125 units/L 1173 units/L 093 units/L
Values may be slightly elevated in older adults.

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36 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

elevated ALP levels, such as biliary


DESCRIPTION: Alkaline phospha- obstruction, hepatobiliary disease,
tase (ALP) is an enzyme found in and bone disease, including malig-
the liver; in Kupffer cells lining
A the biliary tract; and in bones,
nant processes
Differentiate obstructive hepato-
intestines, and placenta. biliary tract disorders from
Additional sources of ALP hepatocellular disease; greater
include the proximal tubules of elevations of ALP are seen in the
the kidneys, pulmonary alveolar former
cells, germ cells, vascular bed, Determine effects of renal disease
lactating mammary glands, and on bone metabolism
granulocytes of circulating Determine bone growth or destruc-
blood. ALP is referred to as tion in children with abnormal
alkaline because it functions growth patterns
optimally at a pH of 9.0. This test
is most useful for determining POTENTIAL DIAGNOSIS
the presence of liver or bone
disease. Increased in
Related to release of alkaline
Isoelectric focusing methods
phosphatase from damaged bone,
can identify 12 isoenzymes of
biliary tract, and liver cells
ALP. Certain cancers produce
small amounts of distinctive Liver disease:
Regan and Nagao ALP isoen- Biliary atresia
zymes. Elevations in three main Biliary obstruction (acute cholecystitis,
ALP isoenzymes, however, are of cholelithiasis, intrahepatic cholestasis
clinical significance: ALP1 of liver of pregnancy, primary biliary
origin, ALP2 of bone origin, and cirrhosis)
ALP3 of intestinal origin (normal Cancer
elevations are present in Lewis Chronic active hepatitis
antibody positive individuals Cirrhosis
Diabetes (diabetic hepatic lipidosis)
with blood types O and B). ALP
Extrahepatic duct obstruction
levels vary by age and gender.
Granulomatous or infiltrative liver
Values in children are higher
diseases (sarcoidosis,
than in adults because of the amyloidosis, TB)
level of bone growth and devel- Infectious mononucleosis
opment. An immunoassay meth- Intrahepatic biliary hypoplasia
od is available for measuring Toxic hepatitis
bone-specific ALP as an indicator Viral hepatitis
of increased bone turnover and Bone disease:
estrogen deficiency in postmeno- Healing fractures
pausal women. Metabolic bone diseases (rickets,
osteomalacia)
Metastatic tumors in bone
This procedure is Osteogenic sarcoma
contraindicated for: N/A Osteoporosis
Pagets disease (osteitis deformans)
Other conditions:
INDICATIONS Advanced pregnancy (related to
Evaluate signs and symptoms of additional sources: placental tissue
various disorders associated with and new fetal bone growth; marked

Monograph_A_024-046.indd 36 17/11/14 12:03 PM


Alkaline Phosphatase and Isoenzymes 37

decline is seen with placental ethionamide, foscarnet, gentamicin,


insufficiency and imminent fetal indomethacin, lincomycin,
demise) methyldopa, naproxen, nitrofurans,
Cancer of the breast, colon, gallbladder,
lung, or pancreas
probenecid, procainamide, proges- A
terone, ranitidine, tobramycin,
Congestive heart failure
tolcapone, and verapamil.
Familial hyperphosphatemia
Drugs that may cause an overall
Hyperparathyroidism
decrease in ALP levels include
Perforated bowel
Pneumonia
alendronate, azathioprine,
Pulmonary and myocardial infarctions calcitriol, clofibrate, estrogens
Pulmonary embolism with estrogen replacement
Ulcerative colitis therapy, and ursodiol.
Hemolyzed specimens may cause
Decreased in falsely elevated results.
Anemia (severe) Elevations of ALP may occur if
Celiac disease the patient is nonfasting, usually
Folic acid deficiency 2 to 4 hr after a fatty meal, and
HIV-1 infection especially if the patient is a
Hypervitaminosis D Lewis-positive secretor of blood
Hypophosphatasia (related to insuffi- group B or O.
cient phosphorus source for ALP
production; congenital and rare)
Hypothyroidism (characteristic in
infantile and juvenile cases) NURSING IMPLICATIONS
Nutritional deficiency of zinc or AND PROCEDURE
magnesium PRETEST:
Pernicious anemia Positively identify the patient using at
Scurvy (related to vitamin C least two unique identifiers before pro-
deficiency) viding care, treatment, or services.
Whipples disease Patient Teaching: Inform the patient this
Zollinger-Ellison syndrome test can assist with determining the
presence of liver or bone disease.
Obtain a history of the patients
CRITICAL FINDINGS: N/A complaints, including a list of known
allergens, especially allergies or
INTERFERING FACTORS sensitivities to latex.
Drugs that may increase ALP lev- Obtain a history of the patients
hepatobiliary and musculoskeletal
els by causing cholestasis include systems, symptoms, and results
anabolic steroids, erythromycin, of previously performed laboratory
ethionamide, gold salts, imipra- tests and diagnostic and surgical
mine, interleukin-2, isocarboxazid, procedures.
nitrofurans, oral contraceptives, Obtain a list of the patients current
phenothiazines, sulfonamides, medications, including herbs, nutri-
and tolbutamide. tional supplements, and nutraceuticals
Drugs that may increase ALP levels (see Appendix H online at DavisPlus).
by causing hepatocellular damage Review the procedure with the
patient. Inform the patient that speci-
include acetaminophen (toxic), men collection takes approximately
amiodarone, anticonvulsants, arsen- 5 to 10 min. Address concerns about
icals, asparaginase, bromocriptine, pain and explain that there may be
captopril, cephalosporins, some discomfort during the
chloramphenicol, enflurane, venipuncture.

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38 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

Sensitivity to social and cultural issues, be required if esophageal varices have


as well as concern for modesty, is developed. Ammonia levels may be
important in providing psychological used to determine whether protein
support before, during, and after the should be added to or reduced from
A procedure. the diet. Patients should be encour-
Note that there are no food, fluid, or aged to eat simple carbohydrates and
medication restrictions unless by medi- emulsified fats (as in homogenized
cal direction. milk or eggs) rather than complex
carbohydrates (e.g., starch, fiber, and
INTRATEST: glycogen [animal carbohydrates]) and
Potential Complications: N/A
complex fats, which require additional
bile to emulsify them so that they can
Avoid the use of equipment containing be used. The cirrhotic patient should
latex if the patient has a history of aller- be carefully observed for the develop-
gic reaction to latex. ment of ascites, in which case fluid
Instruct the patient to cooperate fully and electrolyte balance requires strict
and to follow directions. Direct the attention.
patient to breathe normally and to Reinforce information given by the
avoid unnecessary movement. patients HCP regarding further test-
Observe standard precautions, and fol- ing, treatment, or referral to another
low the general guidelines in Appendix A. HCP. Answer any questions or
Positively identify the patient, and label address any concerns voiced by the
the appropriate specimen container patient or family.
with the corresponding patient Depending on the results of this
demographics, initials of the person procedure, additional testing may be
collecting the specimen, date, and performed to evaluate or monitor
time of collection. Perform a progression of the disease process
venipuncture. and determine the need for a change
Remove the needle and apply direct in therapy. Evaluate test results in
pressure with dry gauze to stop relation to the patients symptoms
bleeding. Observe/assess venipuncture and other tests performed.
site for bleeding and hematoma forma-
tion and secure gauze with adhesive RELATED MONOGRAPHS:
bandage.
Related tests include acetaminophen,
Promptly transport the specimen to the
ALT, albumin, ammonia, anti-DNA
laboratory for processing and analysis.
antibodies, AMA/ASMA, ANA,
1-antitrypsin, 1-antitrypsin phenotyp-
POST-TEST: ing, AST, bilirubin, biopsy bone, biopsy
Inform the patient that a report of the liver, bone scan, BMD, calcium,
results will be made available to the ceruloplasmin, collagen cross-linked
requesting health-care provider (HCP), telopeptides, C3 and C4, complements,
who will discuss the results with the copper, ERCP, GGT, hepatitis antigens
patient. and antibodies, hepatobiliary scan,
Nutritional Considerations: Increased ALP KUB studies, magnesium, MRI abdo-
levels may be associated with liver dis- men, MRI venography, osteocalcin,
ease. Dietary recommendations may PTH, phosphorus, potassium, protein,
be indicated and vary depending on protein electrophoresis, PT/INR,
the severity of the condition. A low- salicylate, sodium, US abdomen,
protein diet may be in order if the US liver, vitamin D, and zinc.
patients liver has lost the ability to See the Hepatobiliary and Musculoskele
process the end products of protein tal systems tables at the end of the
metabolism. A diet of soft foods may book for related tests by body system.

Monograph_A_024-046.indd 38 17/11/14 12:03 PM


Allergen-Specific Immunoglobulin E 39

Allergen-Specific Immunoglobulin E A
SYNONYM/ACRONYM: Allergen profile, radioallergosorbent test (RAST), ImmunoCAP
Specific IgE.

COMMON USE: To assist in identifying environmental allergens responsible for


causing allergic reactions.

SPECIMEN: Serum (2 mL per group of six allergens, 0.5 mL for each additional
individual allergen) collected in a gold-, red-, or red/gray-top tube.

NORMAL FINDINGS: (Method: Radioimmunoassay or fluorescence enzyme


immunoassay)

RAST Scoring Method (Radioimmunoassay)


and ImmunoCAP Scoring Guide Conventional and SI units
(Fluorescence Enzyme Immunoassay) Allergen Specific IgE
Specific IgE Allergen Antibody Level kU/L
Absent or undetectable allergy Less than 0.35
Low allergy 0.350.7
Moderate allergy 0.713.5
High allergy 3.5117.5
Very high allergy 17.550
Very high allergy 51100
Very high allergy Greater than 100

DESCRIPTION:Allergen-specific allergies, and potentially fatal


immunoglobulin E (IgE) is reactions to insect venom, peni-
generally requested for groups of cillin, and other drugs or chemi-
allergens commonly known to cals. RAST and non-radiolabeled
incite an allergic response in the methods are alternatives to skin
affected individual. The test is test anergy and provocation
based on the use of a radiola- procedures, which can be incon-
beled or non-radiolabeled anti- venient, painful, and potentially
IgE reagent to detect IgE in the hazardous to patients.
patients serum, produced in ImmunoCAP FEIA is a newer,
response to specific allergens. nonradioactive technology with
The panels include allergens minimal interference from non-
such as animal dander, antibiot- specific binding to total IgE
ics, dust, foods, grasses, insects, versus allergen-specific IgE.
trees, mites, molds, venom, and A nasal smear can be
weeds. Allergen testing is examined for the presence of
useful for evaluating the cause eosinophils to screen for allergic
of hay fever, extrinsic asthma, conditions. Either a single smear
atopic eczema, respiratory or smears of nasal secretions

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40 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

Atopic dermatitis
from each side of the nose Echinococcus infection
should be submitted, at room Eczema
temperature, for Hansel staining Hay fever
A and evaluation. Normal findings Hookworm infection
vary by laboratory but generally, Latex allergy
greater than 1015% is consid- Schistosomiasis
ered eosinophilia or increased Visceral larva migrans
presence of eosonophils. Results
may be invalid for patients Decreased in
already taking local or Asthma (endogenous)
systemic corticosteroids. Pregnancy
Radiation therapy
This procedure is CRITICAL FINDINGS: N/A
contraindicated for: N/A
INTERFERING FACTORS
INDICATIONS Recent radioactive scans or radiation
Evaluate patients who refuse to within 1 wk of the test can interfere
submit to skin testing or who have with test results when radioimmuno-
generalized dermatitis or other der- assay is the test method.
matopathic conditions
Monitor response to desensitization
procedures
Test for allergens when skin test- NURSING IMPLICATIONS
ing is inappropriate, such as in AND PROCEDURE
infants
PRETEST:
Test for allergens when there is a
known history of allergic reaction Positively identify the patient using at
least two unique identifiers before pro-
to skin testing
viding care, treatment, or services.
Test for specific allergic sensitivity Patient Teaching: Inform the patient this
before initiating immunotherapy or test can assist in identification of
desensitization shots causal factors related to allergic
Test for specific allergic sensitivity reaction.
when skin testing is unreliable Obtain a history of the patients com-
(patients taking long-acting antihis- plaints, including a list of known aller-
tamines may have false-negative gens, especially allergies or sensitivities
skin test) to latex.
Obtain a history of the patients
immune and respiratory systems,
POTENTIAL DIAGNOSIS symptoms, and results of previously
Different scoring systems are used in performed laboratory tests and diag-
the interpretation of RAST results. nostic and surgical procedures.
Note any recent procedures that can
Increased in interfere with test results.
Related to production of IgE, the Obtain a list of the patients current
antibody that primarily responds medications, including herbs, nutri-
to conditions that stimulate an tional supplements, and nutraceuticals
allergic response (see Appendix H online at DavisPlus).
Review the procedure with the patient.
Allergic rhinitis Inform the patient that specimen col-
Anaphylaxis lection takes approximately 5 to 10 min.
Asthma (exogenous) Address concerns about pain and

Monograph_A_024-046.indd 40 17/11/14 12:03 PM


Alveolar/Arterial Gradient and Arterial/Alveolar Oxygen Ratio 41

explain that there may be some present. Lifestyle adjustments may be


discomfort during the venipuncture. necessary depending on the specific
Note that there are no food, fluid, or allergens identified.
medication restrictions unless by Recognize anxiety related to test
medical direction. results. Administer allergy treatment A
if ordered. As appropriate, educate
INTRATEST: the patient in the proper technique
Potential Complications: N/A for administering his or her own
treatments as well as safe handling
Avoid the use of equipment containing
and maintenance of treatment
latex if the patient has a history of aller-
materials. Treatments may include
gic reaction to latex.
eye drops, inhalers, nasal sprays,
Instruct the patient to cooperate fully
oral medications, or shots. Remind
and to follow directions. Direct the
the patient of the importance of
patient to breathe normally and to
avoiding triggers and of being in
avoid unnecessary movement.
compliance with the recommended
Observe standard precautions, and fol-
therapy, even if signs and symptoms
low the general guidelines in Appendix A.
disappear.
Positively identify the patient, and label
Reinforce information given by the
the appropriate specimen container
patients HCP regarding further test-
with the corresponding patient demo-
ing, treatment, or referral to another
graphics, initials of the person collect-
HCP. Answer any questions or
ing the specimen, date, and time of
address any concerns voiced by the
collection. Inform the laboratory of the
patient or family.
specific allergen group to be tested.
Depending on the results of this
Perform a venipuncture.
procedure, additional testing may be
Remove the needle and apply direct
performed to evaluate or monitor
pressure with dry gauze to stop bleed-
progression of the disease process
ing. Observe/assess venipuncture site for
and determine the need for a change
bleeding and hematoma formation and
in therapy. Evaluate test results in
secure gauze with adhesive bandage.
relation to the patients symptoms
Promptly transport the specimen to the
and other tests performed.
laboratory for processing and analysis.
POST-TEST: RELATED MONOGRAPHS:
Inform the patient that a report of the Related tests include arterial/alveolar
results will be made available to the oxygen ratio, blood gases, CBC,
requesting health-care provider (HCP), eosinophil count, fecal analysis, hyper-
who will discuss the results with the sensitivity pneumonitis, IgE, and PFT.
patient. See the Immune and Respiratory
Nutritional Considerations: Should be systems tables at the end of the book
given to diet if food allergies are for related tests by body system.

Alveolar/Arterial Gradient and


Arterial/Alveolar Oxygen Ratio
SYNONYM/ACRONYM: Alveolar-arterial difference, A/a gradient, a/A ratio.

COMMON USE: To assist in assessing oxygen delivery and diagnosing causes of


hypoxemia such as pulmonary edema, acute respiratory distress syndrome, and
pulmonary fibrosis.
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42 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

SPECIMEN: Arterial blood (1 mL) collected in a heparinized syringe. Specimen


should be transported tightly capped and in an ice slurry.

A NORMAL FINDINGS: (Method: Selective electrodes that measure Po2 and Pco2)
as arteriovenous fistulas, burns,
Alveolar/ Less than 10 mm Hg tumors, vascular grafts
arterial at rest (room air)
gradient POTENTIAL DIAGNOSIS
2030 mm Hg at
maximum exercise Increased in
activity (room air) Acute respiratory distress syndrome
Arterial/ Greater than 0.75 (ARDS) (related to thickened
alveolar (75%) edematous alveoli)
oxygen Atelectasis (related to mixing
ratio oxygenated and unoxygenated
blood)
Arterial-venous shunts (related to
mixing oxygenated and unoxy-
This procedure is
genated blood)
contraindicated for
Bronchospasm (related to
Arterial puncture in any of the follow-
decrease in the diameter of the
ing circumstances:
airway)
Inadequate circulation as Chronic obstructive pulmonary
evidenced by an abnormal disease (related to decrease in
(negative) Allen test or the the elasticity of lung tissue)
absence of a radial artery pulse Congenital cardiac septal defects
Significant or uncontrolled (related to mixing oxygenated
bleeding disorder as the and unoxygenated blood)
procedure may cause excessive Underventilated alveoli (related to
bleeding; caution should be used mucus plugs)
when performing an arterial Pneumothorax (related to col-
puncture on patients receiving lapsed lung, shunted air, and
anticoagulant therapy or subsequent decrease in arterial
thrombolytic medications oxygen levels)
Infection at the puncture Pulmonary edema (related to
site carries the potential for thickened edematous alveoli)
introducing bacteria from the Pulmonary embolus (related
skin surface into the blood to obstruction of blood flow
stream to alveoli)
Congenital or acquired Pulmonary fibrosis (related to
abnormalities of the skin or thickened edematous alveoli)
blood vessels in the area of the
anticipated puncture site such CRITICAL FINDINGS: N/A
Find and print out the full monograph at DavisPlus (http://davisplus.fadavis
.com, keyword Van Leeuwen).

Monograph_A_024-046.indd 42 17/11/14 12:03 PM


Alzheimers Disease Markers 43

Alzheimers Disease Markers A


SYNONYM/ACRONYM: CSF tau protein and -amyloid-42,AD,APP, PS-1, PS-2,Apo E4.

COMMON USE: To assist in diagnosing Alzheimers disease and monitoring the


effectiveness of therapy.

SPECIMEN: Cerebrospinal fluid (CSF) (2 mL) collected in a plain plastic conical


tube for tau protein and -amyloid-42; whole blood from one full lavender-top
(EDTA) tube for apolipoprotein E4 (ApoE4) genotyping, -amyloid precursor
protein, presenilin 1, and presenilin 2.

NORMAL FINDINGS: (Method:Enzyme-linked immunosorbent assay) Simultaneous


tau protein and -amyloid-42 measurements in CSF are used in conjunction
with detection of apolipoprotein E4 alleles (restriction fragment length poly-
morphism) and identification of mutations in the -amyloid precursor protein
(APP), presenilin 1 (PS-1) and presenilin 2 (PS-2) genes (polymerase chain
reaction and DNA sequencing) as biochemical and genetic markers of
Alzheimers disease (AD). Scientific studies indicate that a combination
of elevated tau protein and decreased -amyloid-42 protein levels are consis-
tent with the presence of AD. The testing laboratory should be consulted for
interpretation of results.

DESCRIPTION: AD is the most com- reflect the number of neurofibril-


mon cause of dementia in the lary tangles and may be an indica-
elderly population. AD is a disor- tion of the severity of the disease.
der of the central nervous system -Amyloid-42 is a free-floating
(CNS) that results in progressive protein normally present in CSF.
and profound memory loss fol- It is believed to accumulate in
lowed by loss of cognitive abili- the CNS of patients with AD,
ties and death. It may follow causing the formation of amyloid
years of progressive formation of plaques on brain tissue. The result
-amyloid plaques and brain tan- is that these patients have lower
gles, or it may appear as an early- CSF values than age-matched
onset form of the disease. Two healthy control participants. The
recognized pathologic features of study of genetic markers of AD
AD are neurofibrillary tangles has led to an association between
and amyloid plaques found in the an inherited autosomal dominant
brain. Abnormal amounts of the mutation in the APP, PS-1, and
phosphorylated microtubule- PS-2 genes and overproduction of
associated tau protein are the amyloid proteins. Mutations in
main component of the classic these genes are believed to be
neurofibrillary tangles found in responsible for some cases of
patients with AD. Tau protein early-onset AD. An association also
concentration is believed to exists between a gene that codes

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44 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

INTERFERING FACTORS
for the production of ApoE4 and Some patients with AD may have
development of late-onset AD. normal levels of tau protein
Diagnosis of AD includes a thor-
A ough physical examination, a
because of an insufficient number
of neurofibrillary tangles.
complete medical history, neuro-
logical examination, tests of men-
tal status, blood tests, and brain
imaging procedures.
NURSING IMPLICATIONS
AND PROCEDURE
This procedure is PRETEST:
contraindicated for Positively identify the patient using
Patients with infection present at least two unique identifiers
at the needle insertion site. before providing care, treatment,
Patients with degenerative or services.
joint disease or coagulation Patient Teaching: Inform the patient
defects. this test can assist in diagnosing
Patients who are uncoopera- AD and/or evaluating the
tive during the procedure. effectiveness of medication used
to treat AD.
Patients with increased intracra-
Obtain a history of the patients com-
nial pressure because overly plaints, including a list of known aller-
rapid removal of CSF can result gens, especially allergies or sensitivities
in herniation. to latex or anesthetics.
Obtain a history of the patients neuro-
logical system, symptoms, and results
INDICATIONS of previously performed laboratory
Assist in establishing a diagnosis tests and diagnostic and surgical
of AD procedures.
Obtain a list of the patients current
medications, including herbs, nutri-
POTENTIAL DIAGNOSIS tional supplements, and nutraceuticals
(see Appendix H online at DavisPlus).
Increased in Review the procedure with the
Tau protein is increased in AD. patient. Inform the patient that
Presence of ApoE4 alleles is a genetic the procedure will be performed by a
risk factor for AD. health-care provider (HCP) trained to
Identification of mutations in the perform the procedure and takes
APP, PS-1, and PS-2 genes is associ- approximately 20 min. Address con-
ated with forms of AD. cerns about pain and explain that
there may be some discomfort during
Decreased in the lumbar puncture. Inform the
a-Amyloid-42 is decreased in up to patient that a stinging sensation may
50% of healthy control participants. be felt as the local anesthetic is
injected. Instruct the patient to report
AD (related to accumulation in any pain or other sensations that
the brain with a corresponding may require repositioning of the spi-
decrease in CSF) nal needle.
Creutzfeldt-Jakob disease Inform the patient that the position
required for the lumbar puncture may
be awkward but that someone will
CRITICAL FINDINGS: N/A assist. Stress the importance of

Monograph_A_024-046.indd 44 17/11/14 12:03 PM


Alzheimers Disease Markers 45

remaining still and breathing normally Record baseline vital signs, and assess
throughout the procedure. neurological status. Protocols may vary
Sensitivity to social and cultural issues, among facilities.
as well as concern for modesty, is To perform a lumbar puncture,
important in providing psychological position the patient in the knee-chest A
support before, during, and after the position at the side of the bed.
procedure. Provide pillows to support the spine
Note that there are no food, fluid, or for the patient to grasp. The
or medication restrictions unless by sitting position is an alternative.
medical direction. In this position, the patient must
Make sure a written and informed bend the neck and chest to the
consent has been signed prior to the knees.
procedure and before administering Prepare the site (usually between
any medications. L3 and L4 or L4 and L5) with
povidone-iodine, and drape the area.
INTRATEST: Inject a local anesthetic. Using sterile
technique, the HCP inserts the spinal
Potential Complications: needle through the spinous pro-
Headache is a common minor com- cesses of the vertebrae and into the
plication experienced after lumbar subarachnoid space. Needle size
puncture and is caused by leakage has been shown to play a significant
of the spinal fluid from around the role in predictable incidence of post-
puncture site. On a rare occasion the puncture headache. However, the
headache may require treatment with smaller the bevel, the more time is
an epidural blood patch in which an required to collect a sufficient volume
anesthesiologist or pain management of fluid; usually a 22g needle is
specialist injects a small amount of used. The stylet is removed. CSF
the patients blood in the epidural drips from the needle if it is properly
space of the puncture site. The placed.
blood patch forms a clot and seals Attach the stopcock and manometer,
the puncture site to prevent further and measure initial CSF pressure.
leakage of CSF and provides relief Normal pressure for an adult in
within 30 minutes. Other complica- the lateral recumbent position is
tions include lower back pain after 60200 mm H2O, and 10100 mm
the procedure, bleeding near the H2O for children less than 8 yr.
puncture site, or brain stem hernia- These values depend on the body
tion, due to increased intracranial position and are different in a
pressure. horizontal or sitting position. CSF
Avoid the use of equipment contain- pressure may be elevated if the
ing latex if the patient has a history patient is anxious, holding his or
of allergic reaction to latex. her breath, tensing muscles, or if
Instruct the patient to cooperate the patients knees are flexed too
fully and to follow directions. firmly against the abdomen. CSF
Direct the patient to breathe pressure may be significantly
normally and to avoid unnecessary elevated in patients with intracranial
movement. tumors or space occupying
Observe standard precautions, and pockets of infection as seen in
follow the general guidelines in meningitis.
Appendix A. Positively identify the If the initial pressure is elevated, the
patient, and label the appropriate HCP may perform Queckenstedts
specimen container with the test. To perform this test, apply
corresponding patient demographics, pressure to the jugular vein for
initials of the person collecting the about 10 sec. CSF pressure usually
specimen, date, and time of rises in response to the occlusion,
collection. then rapidly returns to normal within

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46 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

10 sec after the pressure is released. Position the patient flat, either on the
Sluggish response may indicate back or abdomen, although some
CSF obstruction. HCPs allow 30 degrees of elevation.
Obtain four (or five) vials of fluid, Maintain this position for 8 hr.
A according to the HCPs request, in Changing position is acceptable as
separate tubes (1 to 3 mL in each), long as the body remains horizontal.
and label them numerically (1 to 4 or Observe/assess the patient for neuro-
5) in the order in which they were logical changes, such as altered level
filled. Take a final pressure reading, of consciousness, change in pupils,
and remove the needle. Clean the reports of tingling or numbness, and
puncture site with an antiseptic irritability.
solution, and apply direct pressure Recognize anxiety related to test
with dry gauze to stop bleeding or results, and be supportive of per-
CSF leakage. Observe/assess ceived loss of independence and
puncture site for bleeding, CSF fear of shortened life expectancy.
leakage, or hematoma formation, Discuss the implications of
and secure gauze with adhesive abnormal test results on the patients
bandage. lifestyle. Provide teaching and
Promptly transport the specimen to information regarding the clinical
the laboratory for processing and implications of the test results, as
analysis. appropriate. Educate the patient
and family members regarding
POST-TEST: access to counseling and other
Inform the patient that a report of the supportive services. Provide
results will be made available to the contact information, if desired,
requesting HCP, who will discuss for the Alzheimers Association
the results with the patient. (www.alz.org).
Monitor vital signs and neurologic Reinforce information given by the
status every 15 min for 1 hr, then patients HCP regarding further testing,
every 2 hr for 4 hr, and as ordered treatment, or referral to another HCP.
after lumbar puncture. Take the tem- Answer any questions or address any
perature every 4 hr for 24 hr. Compare concerns voiced by the patient or
with baseline values. Protocols may family.
vary among facilities. Depending on the results of this
Administer fluids if permitted, especially procedure, additional testing may be
fluids containing caffeine, to replace performed to evaluate or monitor pro-
lost CSF and help prevent or relieve gression of the disease process and
headache, which is a side effect of determine the need for a change in
lumbar puncture. Advise the patient therapy. Evaluate test results in relation
that headache may begin within a few to the patients symptoms and other
hours up to 2 days after the procedure tests performed.
and may be associated with dizziness,
nausea, and vomiting. The length of RELATED MONOGRAPHS:
time for the headache to resolve varies Related tests include CT brain, evoked
considerably. brain potentials, MRI brain, and
Observe/assess the puncture site for FDG-PET scan.
leakage, and frequently monitor body See the Musculoskeletal System table
signs, such as temperature and blood at the end of the book for related tests
pressure. by body system.

Monograph_A_024-046.indd 46 17/11/14 12:03 PM


Amino Acid Screen, Blood 47

Amino Acid Screen, Blood A


SYNONYM/ACRONYM: N/A.

COMMON USE: To assist in diagnosing congenital metabolic disorders in infants,


typically homocystinuria, maple syrup urine disease, phenylketonuria (PKU),
tyrosinuria, and unexplained mental retardation.

SPECIMEN: Plasma (1 mL) collected in a green-top (heparin) tube.

NORMAL FINDINGS: (Method: Liquid chromatography/mass spectrometry) There


are numerous amino acids. Values vary, and the testing laboratory should be
consulted for corresponding ranges.

This procedure is death and decreased deamination


contraindicated for: N/A due to impaired liver function)
Decreased in
POTENTIAL DIAGNOSIS
Decreased (total amino acids) in
Increased in conditions that result in increased
Increased amino acid accumulation renal excretion or insufficient pro-
(total amino acids) occurs when a tein intake or synthesis:
specific enzyme deficiency prevents
Adrenocortical hyperfunction
its catabolism, with liver disease, or
(related to excess cortisol, which
when there is impaired clearance by
assists in conversion of amino
the kidneys:
acids into glucose)
Aminoacidopathies (usually related Carcinoid syndrome (related to
to an inherited disorder; specific increased consumption of amino
amino acids are implicated) acids, especially tryptophan, to
Burns (related to increased pro- form serotonin)
tein turnover) Fever (related to increased
Diabetes (related to gluconeogene- consumption)
sis, where protein is broken down Glomerulonephritis (related to
as a means to generate glucose) increased renal excretion)
Fructose intolerance (related to Hartnups disease (related to
hereditary enzyme deficiency) increased renal excretion)
Malabsorption (related to lack of Huntingtons chorea (related
transport and opportunity for to increased consumption due
catabolism) to muscle tremors; possible
Renal failure (acute or chronic) insufficient intake)
(related to impaired clearance) Malnutrition (related to insuffi-
Reyes syndrome (related to liver cient intake)
damage) Nephrotic syndrome (related to
Severe liver damage (related to increased renal excretion)
decreased production of amino Pancreatitis (acute) (related to
acids by the liver) increased consumption as part
Shock (related to increased of the inflammatory process and
protein turnover from tissue increased ureagenesis)
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48 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

Polycystic kidney disease (related intake evidenced by lack of


to increased renal excretion) appetite)
Rheumatoid arthritis
A (related to insufficient CRITICAL FINDINGS: N/A
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.com, keyword Van Leeuwen).

Amino Acid Screen, Urine


SYNONYM/ACRONYM: N/A.

COMMON USE: To assist in diagnosing congenital metabolic disorders in infants,


typically homocystinuria, maple syrup urine disease, phenylketonuria (PKU),
tyrosinuria, and unexplained mental retardation.

SPECIMEN: Urine (10 mL) from a random or timed specimen collected in a


clean plastic collection container with hydrochloric acid as a preservative.

NORMAL FINDINGS: (Method: Chromatography) There are numerous amino acids.


Values vary, and the testing laboratory should be consulted for corresponding ranges.
This procedure is Secondary causes (noninherited):
contraindicated for: N/A Acute leukemia
Chronic renal failure (reduced glomerular
POTENTIAL DIAGNOSIS filtration rate)
Chronic renal failure
Increased in
Diabetic ketosis
Increased amino acid accumulation Epilepsy (transient increase related
(total amino acids) occurs when a to disturbed renal function during
specific enzyme deficiency prevents grand mal seizure)
its catabolism or when there is Folic acid deficiency
impaired clearance by the kidneys: Hyperparathyroidism
Primary causes (inherited): Liver necrosis and cirrhosis
Aminoaciduria (specific) Multiple myeloma
Cystinosis (may be masked because of Muscular dystrophy (progressive)
decreased glomerular filtration rate, so Osteomalacia (secondary to p arathyroid
values may be in normal range) hormone excess)
Fanconis syndrome Pernicious anemia
Fructose intolerance Thalassemia major
Galactosemia Vitamin deficiency (B, C, and D; vitamin
Hartnups disease Ddeficiency rickets, vitamin
Lactose intolerance Dresistant rickets)
Lowes syndrome Viral hepatitis (related to the degree
Maple syrup urine disease of hepatic involvement)
Tyrosinemia type I Decreased in:N/A
Tyrosinosis
Wilsons disease CRITICAL FINDINGS: N/A

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Monograph_A_047-079.indd 48 17/11/14 12:03 PM


c-aminolevulinic acid 49

c-Aminolevulinic Acid A
SYNONYM/ACRONYM: -ALA.

COMMON USE: To assist in diagnosing lead poisoning in children, or porphyria,


a disorder that disrupts heme synthesis, primarily affecting the liver.

SPECIMEN: Urine (25 mL) from a timed specimen collected in a dark plastic
container with glacial acetic acid as a preservative.

NORMAL FINDINGS: (Method: Spectrophotometry)

Conventional Units SI Units (Conventional Units 7.626)


1.57.5 mg/24 hr 11.457.2 micromol/24 hr

This procedure is Acute porphyrias


contraindicated for: N/A Aminolevulinic acid dehydrase
deficiency (related to the inability
POTENTIAL DIAGNOSIS to convert c-ALA to porphobilino-
Increased in gen, leading to accumulation
Related to inhibition of the enzymes of c-ALA)
involved in porphyrin synthesis; Hereditary tyrosinemia
results in accumulation of c-ALA Lead poisoning
and is evidenced by exposure to Decreased in: N/A
medications, toxins, diet, or infec-
tion that can precipitate an attack CRITICAL FINDINGS

Conventional Units SI Units (Conventional Units 7.62)


Greater than 20 mg/24 hr Greater then 152.4 micromol/24 hr

Note and immediately report to the health-care provider (HCP) abnormal results and associated
symptoms. It is essential that a critical finding be communicated immediately to the requesting
HCP. A listing of these findings varies among facilities. Timely notification of a critical finding for
lab or diagnostic studies is a role expectation of the professional nurse. Notification processes
will vary among facilities. Upon receipt of the critical value the information should be read back
to the caller to verify accuracy. Most policies require immediate notification of the primary HCP,
hospitalist, or on-call HCP. Reported information includes the patient's name, unique identifiers,
critical value, name of the person giving the report, and name of the person receiving the report.
Documentation of notification should be made in the medical record with the name of the HCP
notified, time and date of notification, and any orders received. Any delay in a timely report of a
critical finding may require completion of a notification form with review by Risk Management.
Signs and symptoms of an acute porphyria attack include pain (commonly in the abdomen, arms,
and legs), nausea, vomiting, muscle weakness, rapid pulse, and high blood pressure. Possible
interventions include medication for pain, nausea, and vomiting and, if indicated, respiratory
support. Initial treatment following a moderate to severe attack may include identification and
cessation of harmful drugs the patient may be taking, IV infusion of carbohydrates, and IV heme
therapy (Panhematin) if indicated by markedly elevated urine -ALA and porphyrins.

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50 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

Ammonia
A
SYNONYM/ACRONYM: NH3.

COMMON USE: To assist in diagnosing liver disease such as hepatitis and cirrho-
sis and evaluating the effectiveness of treatment modalities. Specifically used to
assist in diagnosing infant Reyes syndrome.

SPECIMEN: Plasma (1 mL) collected in completely filled lavender- (EDTA) or


green-top (Na or Li heparin) tube. Specimen should be transported tightly
capped and in an ice slurry.

NORMAL FINDINGS: (Method: Enzymatic)

SI Units (Conventional
Age Conventional Units Units 0.587)
Newborn 170340 mcg/dL 100200 micromol/L
10 d24 mo 68136 mcg/dL 4080 micromol/L
25 moAdult 1960 mcg/dL 1135 micromol/L

This procedure is
DESCRIPTION: Blood ammonia contraindicated for: N/A
(NH3) comes from two sources:
deamination of amino acids
during protein metabolism and INDICATIONS
degradation of proteins by colon Evaluate advanced liver disease
bacteria. The liver converts or other disorders associated with
ammonia in the portal blood altered serum ammonia levels
to urea, which is excreted by Identify impending hepatic
the kidneys. When liver function encephalopathy with known
is severely compromised, espe- liver disease
cially in situations in which Monitor the effectiveness of treat
decreased hepatocellular func- ment for hepatic encephalopathy,
tion is combined with impaired indicated by declining levels
portal blood flow, ammonia Monitor patients receiving
levels rise. Congenital enzyme hyperalimentation therapy
defects that prevent the break-
down of ammonia or conditions
POTENTIAL DIAGNOSIS
that affect the ability of the kid-
neys to excrete ammonia can Increased in
also result in increased blood Gastrointestinal hemorrhage (related
levels. Ammonia is potentially to decreased blood volume, which
toxic to the central nervous prevents ammonia from reaching
system and may result in enceph- the liver to be metabolized)
alopathy or coma if toxic levels Genitourinary tract infection with
are reached. distention and stasis (related to

Monograph_A_047-079.indd 50 17/11/14 12:03 PM


Ammonia 51

decreased renal excretion; levels fibrin hydrolysate, furosemide,


accumulate in the blood) hydroflumethiazide, isoniazid,
Hepatic coma (related to insuffi- levoglutamide, mercurial
cient functioning liver cells to diuretics, oral resins, thiazides, A
metabolize ammonia; levels and valproic acid.
accumulate in the blood) Drugs/organisms that may
Inborn enzyme deficiency decrease ammonia levels include
( evidenced by inability to diphenhydramine, kanamycin,
metabolize ammonia) monoamine oxidase inhibitors,
Liver failure, late cirrhosis (related neomycin, tetracycline, and
to insufficient functioning liver Lactobacillus acidophilus.
cells to metabolize ammonia) Hemolysis falsely increases ammo-
Reyes syndrome (related to nia levels because intracellular
insufficient functioning liver ammonia levels are three times
cells to metabolize ammonia) higher than plasma.
Total parenteral nutrition (related Prompt and proper specimen
to ammonia generated from processing, storage, and analysis are
protein metabolism) important to achieve accurate
results. The specimen should be
Decreased in: N/A
collected on ice; the collection
CRITICAL FINDINGS: N/A tube should be filled completely
and then kept tightly stoppered.
INTERFERING FACTORS Ammonia increases rapidly in the
Drugs that may increase ammonia collected specimen, so analysis
levels include asparaginase, should be performed within
chlorthiazide, chlorthalidone, 20 min of collection.

NURSING IMPLICATIONS AND PROCEDURE


Potential Nursing Problems:

Signs &
Problem Symptoms Interventions
Confusion (Related Disorganized Treat the medical condition;
to an alteration in thinking, restless, correlate confusion with the
fluid and electrolytes, irritable, altered need to reverse altered
hepatic disease and concentration and electrolytes; evaluate
encephalopathy; attention span, medications; prevent falls
acute alcohol changeable mental and injury through
consumption; function over the appropriate use of postural
hepatic metabolic day, hallucinations; support, bed alarm, or the
insufficiency) altered attention appropriate use of restraints;
span; unable to consider pharmacological
follow directions; interventions; track accurate
disoriented to intake and output to assess
person, place, fluid status; monitor blood
time, and purpose; ammonia level; determine
inappropriate affect last alcohol use; assess

(table continues on page 52)

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52 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

Signs &
Problem Symptoms Interventions
A for symptoms of hepatic
encephalopathy such as
confusion, sleep
disturbances, incoherence;
protect the patient from
physical harm; administer
lactose as prescribed
Nutrition (Related to Known inadequate Document food intake with
excess alcohol caloric intake; possible calorie count;
intake; insufficient weight loss; assess barriers to eating;
eating habits; muscle wasting in consider using a food diary;
altered liver arms and legs; monitor continued alcohol
function) stool that is pale or use as it is a barrier to
grey colored; skin adequate protein nutrition;
that is flaky with monitor glucose levels;
loss of elasticity monitor daily weight;
perform dietary consult with
assessment of cultural food
selections
Skin (Related to Jaundiced skin and Application of lotion to keep the
jaundice and sclera; dry skin; skin moisturized; avoid
elevated bilirubin itching skin; alkaline soaps; discourage
levels; excessive damage to skin scratching; apply mittens if
scratching) associated with patient is not able to follow
scratching direction to avid scratching;
administer antihistamines as
ordered
Bleeding (Related to Altered level of Increase frequency of vital sign
alerted clotting consciousness; assessment with variances in
factors; portal hypotension; results; monitor for vital sign
hypertension; increased heart trends; administer blood or
esophageal rate; decreased blood products as ordered;
bleeding) HGB and HCT; administer stool softeners as
capillary refill needed; encourage intake of
greater than foods rich in vitamin K; avoid
3 sec; cool foods that may irritate
extremities esophagus

PRETEST: Obtain a history of the patients


Positively identify the patient using at complaints, including a list of known
least two unique identifiers before allergens, especially allergies or
providing care, treatment, or services. sensitivities to latex.
Patient Teaching: Inform the patient this Obtain a history of the patients
test can assist with the evaluation of gastrointestinal, genitourinary, and
liver function related to processing hepatobiliary systems; symptoms;
protein waste. May be used to assist and results of previously performed
in diagnosis of Reyes syndrome in laboratory tests and diagnostic and
infants. surgical procedures.

Monograph_A_047-079.indd 52 17/11/14 12:03 PM


Ammonia 53

Obtain a list of the patients current who will discuss the results with the
medications, including herbs, nutri- patient.
tional supplements, and nutraceuticals Sensitivity to social and cultural issues,as
(see Appendix H online at DavisPlus). well as concern for modesty, is impor-
Review the procedure with the patient. tant in providing psychological support A
Inform the patient that specimen before, during, and after the proce-
collection takes approximately 5 to dure. Recognize anxiety related to
10 min. Address concerns about pain test results, and carefully observe the
and explain that there may be some cirrhotic patient for the development of
discomfort during the venipuncture. ascites, in which case fluid and elec-
Sensitivity to social and cultural issues, trolyte balance require strict attention.
as well as concern for modesty, is Dietary and fluid restrictions may be
important in providing psychological required; diuretics may be ordered.
support before, during, and after the The patient should be frequently moni-
procedure. tored for weight gain, intake and out-
Note that there are no food, fluid, or put, and abdominal girth. The alcoholic
medication restrictions unless by patient should be encouraged to avoid
medical direction. alcohol and also to seek appropriate
counseling for substance abuse.
INTRATEST: Nutritional Considerations: Increased
Potential Complications: N/A
ammonia levels may be associated with
liver disease. Dietary recommendations
Avoid the use of equipment containing may be indicated, depending on the
latex if the patient has a history of aller- severity of the condition. A low-protein
gic reaction to latex. diet may be in order if the patients liver
Instruct the patient to cooperate fully has lost the ability to process the end
and to follow directions. Direct the products of protein metabolism. A diet
patient to breathe normally and to of soft foods may be required if esoph-
avoid unnecessary movement. ageal varices have developed.
Observe standard precautions, and fol- Ammonia levels may be used to deter-
low the general guidelines in Appendix A. mine whether protein should be added
Positively identify the patient, and label to or reduced from the diet. Patients
the appropriate specimen container with should be encouraged to eat simple
the corresponding patient demograph- carbohydrates and emulsified fats (as in
ics, initials of the person collecting the homogenized milk or eggs) rather than
specimen, date, and time of collection. complex carbohydrates (e.g., starch,
Perform a venipuncture. fiber, and glycogen [animal carbohy-
Remove the needle and apply direct drates]) and complex fats, which would
pressure with dry gauze to stop bleed- require additional bile to emulsify them
ing. Observe/assess the v enipuncture so that they could be used.
site for bleeding or h ematoma forma- Depending on the results of this
tion and secure the gauze with procedure, additional testing may be
adhesive bandage. performed to evaluate or monitor
Promptly transport the specimen to the progression of the disease process
laboratory for processing and analysis. and determine the need for a change
The tightly capped sample should be in therapy. Evaluate test results in
placed in an ice slurry immediately after relation to the patients symptoms and
collection. Information on the specimen other tests performed.
label should be protected from water in
the ice slurry by first placing the speci- Patient Education:
men in a protective plastic bag. Reinforce information given by the
patients HCP regarding further testing,
POST-TEST: treatment, or referral to another HCP.
Inform the patient that a report of the Answer any questions or address
results will be made available to the any concerns voiced by the patient
requesting health-care provider (HCP), or family.

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54 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

Teach the patient that small frequent Attitude


meals throughout the day can increase Resolves to participate in counseling
overall caloric intake and improve for alcohol abuse
nutritional status. Follows the recommendations of
A Teach the patient that scratching can the physician and family members
damage the skin and precipitate an in supporting positive health
infection. decisions

Expected Patient Outcomes: RELATED MONOGRAPHS:


Knowledge Related tests include ALT, albumin,
Discusses that adherence to eating analgesic, anti-inflammatory, and
several small meals can improve antipyretic drugs (acetaminophen
caloric intake and acetylsalicylic acid), anion gap,
Associates compliance with taking AST, bilirubin, biopsy liver, blood
lactalose with decreased blood gases, BUN, blood calcium,
ammonia level to help prevent CT biliary tract and liver, CT pelvis,
hepatic encephalopathy cystometry, cystoscopy, EGD,
Skills electrolytes, GI blood loss scan,
Modifies the diet and selects foods that glucose, IVP, MRI pelvis, ketones,
are appropriate for the degree of liver dis- lactic acid, Meckles scan, osmolality,
ease (high protein and high carbohydrate protein, PT/INR, uric acid, and
can support nutrition until liver disease US pelvis.
prohibits these food selections) See the Gastrointestinal, Genitourinary,
Accurately self-administers lactalose as and Hepatobiliary systems tables at
prescribed to reduce absorption of the end of the book for related tests by
ammonia body system.

Amniotic Fluid Analysis and L/S Ratio


SYNONYM/ACRONYM: N/A.

COMMON USE: To assist in identification of fetal gender, genetic disorders such


as hemophilia and sickle cell anemia, chromosomal disorders such as Down
syndrome, anatomical abnormalities such as spina bifida, and hereditary meta-
bolic disorders such as cystic fibrosis. To assess for preterm infant fetal lung
maturity to assist in evaluating for potential diagnosis of respiratory distress
syndrome (RDS).

SPECIMEN: Amniotic fluid (10 to 20 mL) collected in a clean amber glass or


plastic container.

NORMAL FINDINGS: (Method: Macroscopic observation of fluid for color and


appearance, immunochemiluminometric assay [ICMA] for 1-fetoprotein,
electrophoresis for acetylcholinesterase, spectrophotometry for creatinine
and bilirubin, chromatography for lecithin/sphingomyelin [L/S] ratio and
phosphatidylglycerol, tissue culture for chromosome analysis, dipstick for
leukocyte esterase, and automated cell counter for white blood cell count
and lamellar bodies)

Monograph_A_047-079.indd 54 17/11/14 12:03 PM


Amniotic Fluid Analysis and L/S Ratio 55

Test Reference Value


Color Colorless to pale yellow
Appearance Clear A
1-Fetoprotein Less than 2 MoM*
Acetylcholinesterase Absent
Creatinine 1.84 mg/dL at term
Bilirubin Less than 0.075 mg/dL in early pregnancy
Less than 0.025 mg/dL at term
Bilirubin A450 Less than 0.048 OD in early pregnancy
Less than 0.02 OD at term
L/S ratio
Mature (nondiabetic) Greater than 2:1 in the presence of phosphatidyl
glycerol
Borderline 1.5 to 1.9:1
Immature Less than 1.5:1
Phosphatidylglycerol Present at term
Chromosome analysis Normal karyotype
White blood cell count None seen
Leukocyte esterase Negative
Lamellar bodies Findings and interpretive ranges vary depending
on the type of instrument used
*MoM = Multiples of the median.

DESCRIPTION: Amniotic fluid is errors of metabolism. Several


formed in the membranous sac rapid tests are also used to differ-
that surrounds the fetus. The total entiate amniotic fluid from other
volume of fluid at term is 500 to body fluids in a vaginal specimen
2,500 mL. In amniocentesis, fluid when premature rupture of
is obtained by ultrasound-guided membranes (PROM) is suspected.
needle aspiration from the amni- A vaginal swab obtained from the
otic sac. This procedure is general- posterior vaginal pool can be
ly performed between 14 and used to perform a rapid, waived
16 weeks gestation for accurate procedure to aid in the assess-
interpretation of test results, but it ment of PROM. Nitrazine paper
also can be done between 26 and impregnated with an indicator
35 weeks gestation if fetal dis- dye will produce a color change
tress is suspected. Amniotic fluid indicative of vaginal pH. Normal
is tested to identify genetic and vaginal pH is acidic (4.5 to 6) and
neural tube defects, hemolytic dis- the color of the paper will not
eases of the newborn, fetal infec- change. Amniotic fluid has an
tion, fetal renal malfunction, or alkaline pH (7.1 to 7.3) and the
maturity of the fetal lungs. paper will turn a blue color. False-
Examples of genetic defects that positive results occur in the pres-
are commonly tested for and can ence of semen, blood, alkaline
be identified from a sample of urine, vaginal infection, or if the
amniotic fluid include sickle cell patient is receiving antibiotics.
anemia, cystic fibrosis, and inborn The amniotic fluid crystallization

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56 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

or Fern test is based on the obser- Lecithin is the primary surfac-


vation of a fern pattern when tant phospholipid, and it is a stabi-
amniotic fluid is placed on a glass lizing factor for the alveoli. It is
A slide and allowed to air dry. The produced at a low but constant
fern pattern is due to the protein rate until the 35th wk of gestation,
and sodium chloride content of after which its production sharply
the amniotic fluid. False-positive increases. Sphingomyelin, another
results occur in the presence of phospholipid component of
blood urine or cervical mucus. surfactant, is also produced at a
Both of these tests can produce constant rate after the 26th wk of
false-negative results if only a gestation. Before the 35th wk, the
small amount of fluid is leaked. lecithin/sphingomyelin (L/S) ratio
The reliability of results is also is usually less than 1.6:1. The ratio
significantly diminished with the increases to 2 or greater when the
passage of time (greater than rate of lecithin production increas-
24 hr). AmniSure is an immunoas- es after the 35th wk of gestation.
say that can be performed on a Other phospholipids, such as
vaginal swab sample. It is a rapid phosphatidyl glycerol (PG) and
test that detects placental alpha phosphatidyl inositol (PI), increase
microglobulin-1 protein (PAMG-1), over time in amniotic fluid as well.
which is found in high concentra- The presence of PG indicates that
tions in amniotic fluid. AmniSure the fetus is within 2 to 6 wk of
does not demonstrate the high lung maturity (i.e., at full term).
frequency of false-positive and Simultaneous measurement of PG
false-negative results inherent with the L/S ratio improves diag-
with the pH and fern tests. nostic accuracy. Production of
Respiratory distress syndrome phospholipid surfactant is delayed
(RDS) is the most common in diabetic mothers. Therefore,
problem encountered in the care caution must be used when inter-
of premature infants. RDS, also preting the results obtained from a
called hyaline membrane disease, diabetic patient, and a higher ratio
results from a deficiency of is expected to predict maturity.
phospholipid lung surfactants.
The phospholipids in surfactant This procedure is
are produced by specialized contraindicated for
alveolar cells and stored in granu-
lar lamellar bodies in the lung. In Women with a history of prema-
normally developed lungs, ture labor, incompetent cervix,
surfactant coats the surface of the or in the presence of placenta pre-
alveoli. Surfactant reduces the via or abruptio placentae. There is
surface tension of the alveolar some risk to having an amniocente-
wall during breathing. When there sis performed, and this should be
is an insufficient quantity of sur- weighed against the need to obtain
factant, the alveoli are unable to the desired diagnostic information.
expand normally and gas A small percentage (0.5%) of
exchange is inhibited. patients have experienced compli-
Amniocentesis, a procedure by cations including premature rup-
which fluid is removed from the ture of the membranes, premature
amniotic sac, is used to assess labor, spontaneous abortion, and
fetal lung maturity. stillbirth.

Monograph_A_047-079.indd 56 17/11/14 12:03 PM


Amniotic Fluid Analysis and L/S Ratio 57

INDICATIONS POTENTIAL DIAGNOSIS


Assist in the diagnosis of (in utero) Yellow, green, red, or brown
metabolic disorders, such as cystic fluid indicates the presence
fibrosis, or errors of lipid, carbohy- of bilirubin, blood (fetal or A
drate, or amino acid metabolism maternal), or meconium, which
Assist in the evaluation of fetal lung indicate fetal distress or death,
maturity when preterm delivery is hemolytic disease, or growth
being considered retardation.
Detect infection secondary to rup- Elevated bilirubin levels indicate
tured membranes fetal hemolytic disease or intes-
Detect fetal ventral wall defects tinal obstruction. Measurement
Determine the optimal time for of bilirubin is not usually per-
obstetric intervention in cases of formed before 20 to 24 weeks
threatened fetal survival caused by gestation because no action can
stresses related to maternal diabe- be taken before then. The severi-
tes, toxemia, hemolytic diseases of ty of hemolytic disease is grad-
the newborn, or postmaturity ed by optical density (OD)
Determine fetal gender when the zones: A value of 0.28 to 0.46 OD
mother is a known carrier of a sex- at 28 to 31 weeks gestation indi-
linked abnormal gene that could be cates mild hemolytic disease,
transmitted to male offspring, such which probably will not affect
as hemophilia or Duchennes mus- the fetus; 0.47 to 0.9 OD indi-
cular dystrophy cates a moderate effect on the
Determine the presence of fetal fetus; and 0.91 to 1 OD indicates
distress in late-stage pregnancy a significant effect on the fetus.
Evaluate fetus in families with a his- A trend of increasing values
tory of genetic disorders, such as with serial measurements may
Down syndrome, Tay-Sachs disease, indicate the need for intrauter-
chromosome or enzyme anomalies, ine transfusion or early deliv-
or inherited hemoglobinopathies ery, depending on the fetal age.
Evaluate fetus in mothers of After 32 to 33 weeks gestation,
advanced maternal age (some of early delivery is preferred over
the aforementioned tests are rou- intrauterine transfusion,
tinely requested in mothers age because early delivery is more
35 and older) effective in providing the
Evaluate fetus in mothers with a required care to the neonate.
history of miscarriage or stillbirth Creatinine concentration greater
Evaluate known or suspected hemo- than 2 mg/dL indicates fetal
lytic disease involving the fetus in an maturity (at 36 to 37 wk) if
Rh-sensitized pregnancy, indicated by maternal creatinine is also
rising bilirubin levels, especially after within the expected range. This
the 30th week of gestation value should be interpreted in
Evaluate suspected neural tube conjunction with other parame-
defects, such as spina bifida or myelo- ters evaluated in amniotic fluid
meningocele, as indicated by elevat- and especially with the L/S ratio,
ed 1-fetoprotein (see monograph because normal lung develop-
titled 1-Fetoprotein for information ment depends on normal kidney
related to triple-marker testing) development.
Identify fetuses at risk of develop- An L/S ratio less than 2:1 and
ing RDS absence of phosphatidylglycerol at

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58 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

term indicate fetal lung immatu- It is essential that a critical find-


rity and possible respiratory dis- ing be communicated immediately to
tress syndrome. Other conditions the requesting HCP. A listing of these
A that decrease production of sur- findings varies among facilities.
factants include advanced mater- Timely notification of a critical
nal age, multiple gestation, and finding for lab or diagnostic studies is
polyhydramnios. Conditions that a role expectation of the professional
may increase production of sur- nurse. The notification processes will
factant include hypertension, vary among facilities. Upon receipt of
intrauterine growth retardation, the critical finding the information
malnutrition, maternal diabetes, should be read back to the caller to
placenta previa, placental infarc- verify accuracy. Most policies require
tion, and premature rupture of immediate notification of the primary
the membranes. The expected L/S HCP, hospitalist, or on-call HCP.
ratio for the fetus of an insulin- Reported information includes the
dependent diabetic mother is patients name, unique identifiers,
higher (3.5:1). critical finding, name of the person
Lamellar bodies are specialized giving the report, and name of the
alveolar cells in which lung person receiving the report.
surfactant is stored. They are Documentation of notification should
approximately the size of platelets. be made in the medical record with
Their presence in sufficient the name of the HCP notified, time
quantities is an indicator of fetal and date of notification, and any
lung maturity. orders received. Any delay in a timely
Elevated 1-fetoprotein levels report of a critical finding may require
and presence of acetylcholinester- completion of a notification form
ase indicate a neural tube with review by Risk Management.
defect (see monograph titled Infants known to be at risk for
`1-Fetoprotein). Elevation of RDS can be treated with surfactant
acetylcholinesterase is also by intratracheal administration at
indicative of ventral wall birth.
defects.
Abnormal karyotype indicates INTERFERING FACTORS
genetic abnormality (e.g., Bilirubin may be falsely elevated if
Tay-Sachs disease, mental maternal hemoglobin or meconium
retardation, chromosome or is present in the sample; fetal acido-
enzyme anomalies, and inherited sis may also lead to falsely elevated
hemoglobinopathies). (See mono- bilirubin levels.
graph titled Chromosome Analysis, Bilirubin may be falsely decreased
Blood.) if the sample is exposed to light
Elevated white blood cell count or if amniotic fluid volume is
and positive leukocyte esterase are excessive.
indicators of infection. Maternal serum creatinine should
be measured simultaneously for
CRITICAL FINDINGS: An L/S ratio less than comparison with amniotic fluid
1.5:1 is predictive of RDS at the time of creatinine for proper interpreta-
delivery. tion. Even in circumstances in
Note and immediately report to the which the maternal serum value is
health-care provider (HCP) any criti- normal, the results of the amniotic
cally increased or decreased values and fluid creatinine may be misleading.
related symptoms. A high fluid creatinine value in the

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Amniotic Fluid Analysis and L/S Ratio 59

fetus of a diabetic mother may 1-Fetoprotein and acetylcholines-


reflect the increased muscle mass terase may be falsely elevated if the
of a larger fetus. If the fetus is big, sample is contaminated with fetal
the creatinine may be high, and blood. A
the fetus may still have immature Karyotyping cannot be performed
kidneys. under the following conditions:
Contamination of the sample with (1) failure to promptly deliver sam-
blood or meconium or complica- ples for chromosomal analysis to
tions in pregnancy may yield inac- the laboratory performing the test
curate L/S ratios; fetal blood falsely or (2) improper incubation of the
elevates the L/S ratio. sample, which causes cell death.

NURSING IMPLICATIONS AND PROCEDURE


Potential Nursing Problems:

Signs &
Problem Symptoms Interventions
Fear (Related to Verbalization of Evaluate verbal and nonverbal
fetal fear; indicators of fear; assess for the
imperfections restlessness; cause of fear; acknowledge the
secondary to increased patients awareness of fear;
developmental tension; explain all procedures with
abnormality) continuous simple age and culturally
questioning; appropriate language;
increased blood administer proscribed mild
pressure, heart tranquilizer; maintain a confident
rate, respiratory assured professional manner in
rate all patient interactions; address
concerns regarding care of
disabled child; recommend
support group and provide
contact information
Spirituality Anger; stated Obtain a history of the patients
(Related to feelings of lack of religious affiliation; identify the
anxiety peace or serenity; patients willingness to meet
associated stated feelings of with spiritual leader; encourage
with feral alienation from verbalization of concerns,
developmental others; stated feelings of fear and loneliness;
abnormality; feelings of acknowledge and support
unexpected life hopelessness; religious practices;
changes) request to meet accommodate a display of
with spiritual religious objects; facilitate
leader communication between the
patient, family, and religious
leader

(table continues on page 60)

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60 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

Signs &
Problem Symptoms Interventions
A Knowledge Lack of interest or Identify the primary learners and
(Related to questions; provide specific information that
insufficient multiple is culturally appropriate and to
information questions; the correct literacy level; assess
associated anxiety in for the willingness and ability to
with relation to learn; identify the patients
diagnosed disease process priority for learning; identify and
developmental and dispel any misconceptions
abnormality; management; associated with the
lack of stating developmental disability; identify
familiarity or inaccurate the patients learning style;
understanding information; provide a quiet atmosphere for
with disease frustration; learning; allow the parents to be
and treatment) confusion self-directed in their learning;
provide sufficient time for
questions and follow up; refer to
a support group and social
services as appropriate

PRETEST: Record the date of the last menstrual


Positively identify the patient using at period and determine the pregnancy
least two unique identifiers before pro- weeks gestation and expected deliv-
viding care, treatment, or services. ery date.
Patient Teaching: Inform the parent this Obtain a list of the patients current
procedure/test can assist in providing medications, including herbs, nutri-
a sample of fluid that will allow for eval- tional supplements, and nutraceuticals
uation of fetal well-being. (see Appendix H online at DavisPlus).
Obtain a history of the patients com- Review the procedure with the patient.
plaints, including a list of known aller- Warn the patient that normal results do
gens, especially allergies or sensitivities not guarantee a normal fetus. Assure
to latex or anesthetics. the patient that precautions to avoid
Obtain a history of the patients repro- injury to the fetus will be taken by
ductive system, previous pregnancies, localizing the fetus with ultrasound.
symptoms, and results of previously Address concerns about pain and
performed laboratory tests and diag- explain that during the transabdominal
nostic and surgical procedures. Include procedure, any discomfort associated
any family history of genetic disorders with a needle biopsy will be minimized
such as cystic fibrosis, Duchennes with local anesthetics. If the patient is
muscular dystrophy, hemophilia, sickle less than 20 weeks gestation, instruct
cell disease, Tay-Sachs disease, her to drink extra fluids 1 hr before the
thalassemia, and trisomy 21. Obtain test and to refrain from urination. The
maternal Rh type. If Rh-negative, check full bladder assists in raising the uterus
for prior sensitization. A standard dose up and out of the way to provide better
of Rh1(D) immune globulin RhoGAM IM visualization during the ultrasound pro-
or Rhophylac IM or IV is indicated after cedure. Patients who are at 20 weeks
amniocentesis; repeat doses should be gestation or beyond do not need to
considered if repeated amniocentesis drink extra fluids and should void
is performed. before the test, because an empty
Note any recent procedures that can bladder is less likely to be accidentally
interfere with test results. punctured during specimen collection.

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Amniotic Fluid Analysis and L/S Ratio 61

Encourage relaxation and controlled relax the abdominal muscles. If the


breathing during the procedure to aid uterus is large, place a pillow or rolled
in reducing any mild discomfort. Inform blanket under the patients right side to
the patient that specimen collection is prevent hypertension caused by great-
performed by a health-care provider vessel compression. Instruct the A
(HCP) specializing in this procedure patient to cooperate fully and to follow
and usually takes approximately 20 to directions. Direct the patient to breathe
30 min to complete. normally and to avoid unnecessary
Sensitivity to social and cultural issues, movement during the local anesthetic
as well as concern for modesty, is and the procedure.
important in providing psychological Record maternal and fetal baseline vital
support before, during, and after the signs, and continue to monitor
procedure. throughout the procedure. Monitor for
Note that there are no food, fluid, uterine contractions. Monitor fetal vital
or medication restrictions unless by signs using ultrasound. Protocols may
medical direction. vary among facilities.
Make sure a written and informed Have emergency equipment readily
consent has been signed prior to the available.
procedure and before administering Observe standard precautions, and fol-
any medications. low the general guidelines in Appendix
A. Positively identify the patient, and
INTRATEST: label the appropriate specimen con-
tainer with the corresponding patient
Potential Complications: demographics, initials of the person
Hemorrhage from highly vascular tissue collecting the specimen, date, and
or infection following amniocentesis. time of collection.
Instruct the patient to look for excessive Assess the position of the amniotic
bleeding, redness of skin, fever, or chills fluid, fetus, and placenta using
and to notify the HCP if these symp- ultrasound.
toms occur. An additional risk with Assemble the necessary equipment,
amniocentesis is maternal Rh sensitiza- including an amniocentesis tray with
tion by fetal RBCs in the case of an solution for skin preparation, local
Rh-negative mother carrying an anesthetic, 10- or 20-mL syringe, nee-
Rh-positive fetus. RhIG (Rh immune dles of various sizes (including a
globulin) or RhoGam may be adminis- 22-gauge, 5-in. spinal needle), sterile
tered after amniocentesis to drapes, sterile gloves, and foil-covered
Rh-negative mothers to prevent or amber-colored specimen collection
formation of Rh antibodies. containers.
Avoid the use of equipment containing Cleanse suprapubic area with an anti-
latex if the patient has a history of septic solution, and protect with sterile
allergic reaction to latex. drapes. A local anesthetic is injected.
Ensure that the patient has a full bladder Explain that this may cause a stinging
before the procedure if gestation is 20 wk sensation.
or less; have patient void before the Insert a 22-gauge, 5-in. spinal needle
procedure if gestation is 21 wk or more. through the abdominal and uterine
Positively identify the patient, and label walls. Explain that a sensation of pres-
the appropriate collection containers with sure may be experienced when the
the corresponding patient demographics, needle is inserted. Explain to the
date, time of collection, and site location. patient how to use focused and con-
Have patient remove clothes below the trolled breathing for relaxation during
waist. Assist the patient to a supine the procedure.
position on the examination table with Apply slight pressure to the site after
the abdomen exposed. Drape the the fluid is collected and the needle is
patients legs, leaving the abdomen withdrawn. If there is no evidence of
exposed. Raise her head or legs bleeding or other drainage, apply a
slightly to promote comfort and to sterile adhesive bandage to the site.

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62 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

Monitor the patient for complications abnormality is determined. Decisions


related to the procedure (e.g., prema- regarding elective abortion should take
ture labor, allergic reaction, anaphylaxis). place in the presence of both parents.
Provide a nonjudgmental, nonthreaten-
A POST-TEST: ing atmosphere for d iscussing the risks
Inform the patient that a report of the and difficulties of delivering and raising a
results will be made available to the developmentally challenged infant as
requesting HCP, who will discuss the well as for exploring other options (ter-
results with the patient. mination of pregnancy or adoption). It is
Compare fetal heart rate and maternal also important to discuss problems the
life signs (i.e., heart rate, blood pres- mother and father may experience
sure, pulse, and respiration) with base- (guilt, depression, anger) if fetal
line values and closely monitor every abnormalities are detected.
15 min for 30 to 60 min after the amnio- Depending on the results of this
centesis procedure. Protocols may procedure, additional testing may be
vary among facilities. performed to evaluate or monitor
Observe/assess for delayed allergic reac- progression of the disease process
tions, such as rash, urticaria, tachycardia, and determine the need for a change
hyperpnea, hypertension, palpitations, in therapy. Evaluate test results in
nausea, or vomiting. Immediately report relation to the patients symptoms and
symptoms to the appropriate HCP. other tests performed.
Observe/assess the amniocentesis site
Patient Education:
for bleeding, inflammation, or hema-
toma formation. Reinforce information given by the
Instruct the patient in the care and patients HCP regarding further testing,
assessment of the amniocentesis site. treatment, or referral to another HCP.
Instruct the patient to report any red- Inform the patient that it may be 2 to
ness, edema, bleeding, or pain at the 4 wk before all results are available.
amniocentesis site. Answer any questions or address any
Instruct the patient to expect mild cramp- concerns voiced by the patient or family.
ing, leakage of small amounts of amniotic Instruct the patient in the use of any
fluid, and vaginal spotting for up to 2 days ordered medications.
following the procedure. Instruct the
patient to report moderate to severe Expected Patient Outcomes:
abdominal pain or cramps, change in Knowledge
fetal activity, increased or prolonged leak- The patient states understanding of the
ing of amniotic fluid from abdominal nee- importance of adhering to the therapy
dle site, vaginal bleeding that is heavier regimen provided by the HCP.
than spotting, and either chills or fever. The patient states understanding of the
Instruct the patient to rest until all significant side effects and systemic
symptoms have disappeared before reactions associated with the pre-
resuming normal levels of activity. scribed medication.
Administer standard RhoGAM dose to
Skills
maternal Rh-negative patients to pre-
The patient accurately describes care
vent maternal Rh sensitization should
necessary to support the health of the
the fetus be Rh-positive.
developmentally disabled infant.
Recognize anxiety related to test
The patient accurately describes the
results. Discuss the implications of
lifestyle changes that will be necessary
abnormal test results on the patients
to provide care for the developmentally
lifestyle. Provide teaching and informa-
disabled infant.
tion regarding the clinical implications of
the test results, as appropriate. Attitude
Encourage the family to seek The patient complies with the request
appropriate counseling if concerned to review the literature provided by a
with pregnancy termination and to seek pharmacist regarding prescribed
genetic counseling if a chromosomal medications.

Monograph_A_047-079.indd 62 17/11/14 12:04 PM


Amylase 63

The patient agrees to meet with analysis, fetal fibronectin, glucose,


support group in relation to ketones, Kleihauer-Betke test,
diagnosed developmental lupus anticoagulant antibodies,
disability. newborn screening, potassium,
US biophysical profile obstetric, A
RELATED MONOGRAPHS: and UA.
Related tests include 1-fetoprotein, Refer to the Reproductive System
antibodies anticardiolipin, blood table at the end of the book for related
groups and antibodies, chromosome tests by body system.

Amylase
SYNONYM/ACRONYM: N/A.

COMMON USE: To assist in diagnosis and evaluation of the treatment modalities


used for pancreatitis.

SPECIMEN: Serum (1 mL) collected in a gold-, red-, or red/gray-top tube. Plasma


(1 mL) collected in a green-top (heparin) tube is also acceptable.

NORMAL FINDINGS: (Method: Enzymatic)

Age Conventional & SI Units


390 d 030 units/L
36 mo 640 units/L
711 mo 670 units/L
13 yr 1180 units/L
49 yr 1691 units/L
1018 yr 1976 units/L
Adultolder adult 30110 units/L
Values may be slightly elevated in older adults due to the effects of medications and the
presence of multiple chronic or acute diseases with or without muted symptoms.

DESCRIPTION: Amylase is a diges- pancreatic obstruction. Newborns


tive enzyme mainly secreted by and children up to 2 years old
the acinar cells of the pancreas have little measurable serum amy-
and by the parotid glands. lase. In the early years of life, most
Pancreatic amylase is secreted of this enzyme is produced by
into the pancreatic common bile the salivary glands. Amylase can
ducts and then into the duode- be separated into pancreatic
num where it assists in the diges- (P1, P2, P3) and salivary (S1, S2, S3)
tion of carbohydrates by splitting isoenzymes. Isoenzyme patterns
starch into disaccharides. Amylase are useful in identifying the organ
is a sensitive indicator of pancre- source. Requests for amylase
atic acinar cell damage and isoenzymes are rare because of

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64 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

Acute appendicitis (related to


the expense of the procedure and enzyme release from damaged
limited clinical utility of the result. pancreatic tissue)
Isoenzyme analysis is primarily Administration of some drugs (e.g.,
A used to assess decreasing pancre- morphine) is known to increase
atic function in children 5 years amylase levels (related to
and older who have been diag- increased biliary tract pressure
nosed with cystic fibrosis and as evidenced by effect of narcotic
who may be candidates for analgesic drugs)
enzyme replacement. Cyst fluid Afferent loop syndrome (related
amylase levels with isoenzyme to impaired pancreatic duct
analysis is useful in differentiating flow)
pancreatic neoplasms (low Aortic aneurysm (elevated
enzyme concentration) and amylase levels following rupture
pseudocysts (high enzyme are associated with a poor
concentration). Lipase is usually prognosis; both S and P subtypes
ordered in conjunction with amy- have been identified following
lase because lipase is more sensi- rupture. The causes for elevation
tive and specific to conditions are mixed and difficult to state
affecting pancreatic function. as a generalization)
Abdominal trauma (related to
release of enzyme from damaged
This procedure is
pancreatic tissue)
contraindicated for: N/A
Alcoholism (related to increased
secretion; salivary origin most
INDICATIONS
likely)
Assist in the diagnosis of early acute
Biliary tract disease (related to
pancreatitis; serum amylase begins
impaired pancreatic duct flow)
to rise within 6 to 24 hr after onset
Burns and traumatic shock
and returns to normal in 2 to 7 days
Carcinoma of the head of the pan-
Assist in the diagnosis of macroam-
creas (advanced) (related to
ylasemia, a disorder seen in alcohol-
enzyme release from damaged
ism, malabsorption syndrome, and
pancreatic tissue)
other digestive problems
Common bile duct obstruction,
Assist in the diagnosis of pancreatic
common bile duct stones (related
duct obstruction, which causes serum
to impaired pancreatic duct
amylase levels to remain elevated
flow)
Detect blunt trauma or inadvertent
Diabetic ketoacidosis (related to
surgical trauma to the pancreas
increased secretion; salivary
Differentiate between acute pancre-
origin most likely)
atitis and other causes of abdominal
Duodenal obstruction (accumula-
pain that require surgery
tion in the blood as evidenced by
leakage from the gut)
POTENTIAL DIAGNOSIS
Ectopic pregnancy (related to
Increased in ectopic enzyme production by the
Amylase is released from any dam- fallopian tubes)
aged cell in which it is stored, so Extrapancreatic tumors (especially
conditions that affect the pancreas esophagus, lung, ovary)
and parotid glands and cause cellu- Gastric resection (accumulation
lar destruction demonstrate elevated in the blood as evidenced by
amylase levels. leakage from the gut)

Monograph_A_047-079.indd 64 17/11/14 12:04 PM


Amylase 65

Hyperlipidemias (etiology is likely related to hyperemesis


unclear, but there is a distinct or hyperlipidemia induced
association with amylasemia) pancreatitis related to increased
Hyperparathyroidism (etiology is estrogen levels) A
unclear, but there is a distinct asso- Renal disease (related to decreased
ciation with amylasemia) renal excretion as evidenced by
Intestinal obstruction (related to accumulation in blood)
impaired pancreatic duct flow) Some tumors of the lung and ova-
Intestinal infarction (related to ries (related to ectopic enzyme
impaired pancreatic duct flow) production)
Macroamylasemia (related to Tumor of the pancreas or adjacent
decreased ability of renal glom- area (related to release of enzyme
eruli to filter large molecules as from damaged pancreatic tissue)
evidenced by accumulation in the
blood) Decreased in
Mumps (related to increased Hepatic disease (severe) (may be
secretion from inflamed tissue; due to lack of amino acid pro-
salivary origin most likely) duction necessary for enzyme
Pancreatic ascites (related to manufacture)
release of pancreatic fluid into Pancreatectomy
the abdomen and subsequent Pancreatic insufficiency
absorption into the circulation) Toxemia of pregnancy
Pancreatic cyst and pseudocyst
(related to release of pancreatic CRITICAL FINDINGS: N/A
fluid into the abdomen and sub-
sequent absorption into the cir- INTERFERING FACTORS
culation) Drugs and substances that may
Pancreatitis (related to enzyme increase amylase levels include
release from damaged pancreat- acetaminophen, aminosalicylic acid,
ic tissue) amoxapine, asparaginase, azathio-
Parotitis (related to increased prine, bethanechol, calcitriol,
secretion from inflamed tissue; cholinergics, chlorthalidone,
salivary origin most likely) clozapine, codeine, corticosteroids,
Perforated peptic ulcer whether corticotropin, desipramine, dexa-
the pancreas is involved or not methasone, diazoxide, felbamate,
(related to enzyme release from fentanyl, f luvastatin, glucocorti-
damaged pancreatic tissue; coids, hydantoin derivatives, hydro-
involvement of the pancreas chlorothiazide, hydroflumethiazide,
may be unnoticed upon gross meperidine, mercaptopurine,
examination yet be present as methacholine, methyclothiazide,
indicated by elevated enzyme metolazone, minocycline, mor-
levels) phine, nitrofurantoin, opium
Peritonitis (accumulation in the alkaloids, pegaspargase, pentazo-
blood as evidenced by leakage cine, potassium iodide, prednisone,
from the gut) procyclidine, tetracycline, thiazide
Postoperative period (related to diuretics, valproic acid, zalcitabine,
complications of the surgical and zidovudine.
procedure) Drugs that may decrease amylase
Pregnancy (related to increased levels include anabolic steroids,
secretion; salivary origin most citrates, and fluorides.

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66 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

NURSING IMPLICATIONS AND PROCEDURE


Potential Nursing Problems:
A
Problem Signs & Symptoms Interventions
Fluid volume Deficient: decreased Daily weight with
(Related to urinary output, fatigue, monitoring of trends;
vomiting; and sunken eyes, dark accurate intake and
decreased oral urine, decreased output; collaboration
intake; blood pressure, with physician with
diaphoresis; increased heart rate, administration of IV
NPO with NGT; and altered mental fluids to support
overly status. Overload: hydration; monitor
aggressive fluid Edema, shortness of laboratory values that
resuscitation; breath, increased reflect alterations in fluid
compromised weight, ascites, rales, status (potassium, blood
renal function; rhonchi, and diluted urea nitrogen,
overly laboratory values. creatinine, calcium,
aggressive hemoglobin, and
diuresis) hematocrit); manage
underlying cause of fluid
alteration; monitor urine
characteristics and
respiratory status;
establish baseline
assessment data;
collaborate with
physician to adjust oral
and IV fluids to provide
optimal hydration status;
administer replacement
electrolytes as ordered
Nutrition (Related Known inadequate Document food intake
to altered caloric intake; weight with possible calorie
pancreatic loss; muscle wasting count; assess barriers
function excess in arms and legs; stool to eating; consider using
alcohol intake; that is pale or grey a food diary; monitor
insufficient eating colored; skin that is continued alcohol use
habits; altered flaky with loss of as it is a barrier to
pancreatic elasticity adequate protein
function liver nutrition; monitor glucose
function) levels; check daily
weight; arrange dietary
consult with assessment
of cultural food
selections

Monograph_A_047-079.indd 66 17/11/14 12:04 PM


Amylase 67

Problem Signs & Symptoms Interventions


Gas exchange Irregular breathing Monitor respiratory rate and
(Related to pattern, use of effort based on A
accumulation accessory muscles; assessment of patient
of pleural fluid, altered chest condition; assess lung
atelectasis, excursion; adventitious sounds frequently;
ventilation breath sounds monitor for secretions;
perfusion (crackles, rhonchi, suction as necessary; use
mismatch; wheezes, diminished pulse oximetry to monitor
altered oxygen breath sounds); oxygen saturation;
supply) copious secretions; collaborate with physician
signs of hypoxia to administer oxygen as
needed; elevate the head
of the bed 30 degrees;
monitor IV fluids and
avoid aggressive fluid
resuscitation
Pain (Related to Emotional symptoms of Collaborate with the patient
pancreatic distress; crying; and physician to identify
inflammation agitation; facial the best pain
and surrounding grimace; moaning; management modality to
tissues; verbalization of pain; provide relief; refrain from
excessive rocking motions; activities that may
alcohol intake; irritability; disturbed aggravate pain; use the
infection) sleep; diaphoresis; application of heat or cold
altered blood pressure to the best effect in
and heart rate; managing the pain;
nausea; vomiting; self- monitor pain severity
report of pain; upper
abdominal and gastric
pain after eating fatty
foods or alcohol intake
with acute pancreatic
disease; pain may be
decreased or absent
in chronic pancreatic
disease

PRETEST: allergens, especially allergies or


Positively identify the patient using at sensitivities to latex.
least two unique identifiers before Obtain a history of the patients
providing care, treatment, or services. gastrointestinal and hepatobiliary
Patient Teaching: Inform the patient systems, symptoms, and results of pre-
this test can assist in evaluating viously performed laboratory tests and
pancreatic health and/or the effec- diagnostic and surgical p rocedures.
tiveness of medical treatment for Obtain a list of the patients current
pancreatitis. medications, including herbs, nutri-
Obtain a history of the patients tional supplements, and nutraceuticals
complaints, including a list of known (see Appendix H online at DavisPlus).

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68 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

Review the procedure with the patient. patients with gastrointestinal disorders.
Inform the patient that specimen Consideration should be given to
collection takes approximately 5 to dietary alterations in the case of
10 min. Address concerns about pain gastrointestinal disorders. Usually after
A and explain that there may be some acute symptoms subside and bowel
discomfort during the venipuncture. sounds return, patients are given a
Sensitivity to social and cultural issues, clear liquid diet, progressing to a
as well as concern for modesty, is low-fat, high-carbohydrate diet. Vitamin
important in providing psychological B12 may be ordered for parenteral
support before, during, and after the administration to patients with
procedure. decreased levels, especially if their
Note that there are no food, fluid, disease prevents adequate absorption
or medication restrictions unless by of the vitamin. The alcoholic patient
medical direction. should be encouraged to avoid alcohol
and to seek appropriate c ounseling for
INTRATEST: substance abuse.
Depending on the results of this
Potential Complications: procedure, additional testing may be
Avoid the use of equipment containing performed to evaluate or monitor pro-
latex if the patient has a history of gression of the disease process and
allergic reaction to latex. determine the need for a change in
Instruct the patient to cooperate fully therapy. Evaluate test results in relation
and to follow directions. Direct the to the patients symptoms and other
patient to breathe normally and to tests performed.
avoid unnecessary movement.
Patient Education:
Observe standard precautions, and
follow the general guidelines in Teach the patient to use the incentive
Appendix A. Positively identify the spirometer with deep cough to help
patient, and label the appropriate maintain open airways and move
specimen container with the corre- secretions that interfere with adequate
sponding patient demographics, initials oxygenation
of the person collecting the specimen, Teach the patient the symptoms of
date, and time of collection. Perform fluid overload and deficit with an
a venipuncture. explanation of proper hydration.
Remove the needle and apply direct Reinforce information given by the
pressure with dry gauze to stop patients HCP regarding further testing,
bleeding. Observe/assess venipuncture treatment, or referral to another HCP.
site for bleeding or hematoma Recognize anxiety related to test
formation and secure gauze with results, and answer any questions or
adhesive bandage. address any concerns voiced by the
Promptly transport the specimen to patient or family.
the laboratory for processing and
analysis. Expected Patient Outcomes:
Knowledge
POST-TEST: Demonstrates understanding of the
link between alcohol use and disease
Inform the patient that a report of the process
results will be made available to the Describes symptoms that indicate
requesting health-care provider (HCP), being respiratory compromised and
who will discuss the results with the should be reported to the physician
patient.
Nutritional Considerations: Increased Skills
amylase levels may be associated with Accurately self-administers oxygen
gastrointestinal disease or alcoholism. Proficiently monitors intake and output
Small, frequent meals work best for and records results accurately

Monograph_A_047-079.indd 68 17/11/14 12:04 PM


Analgesic, Anti-inflammatory, and Antipyretic Drugs 69

Attitude C-peptide, CBC WBC count and


Conforms with the therapeutic goals differential, CT pancreas, ERCP,
established by the HCP fecal fat, GGT, lipase, magnesium,
Verifies the necessity in refraining from MRI pancreas, mumps serology,
activities that could cause a disease peritoneal fluid analysis, triglycerides, A
reoccurrence US abdomen, and US pancreas.
See the Gastrointestinal and
RELATED MONOGRAPHS: Hepatobiliary systems tables at the
Related tests include ALT, ALP, AST, end of the book for related tests by
bilirubin, cancer antigens, calcium, body system.

Analgesic, Anti-inflammatory, and


Antipyretic Drugs: Acetaminophen,
Acetylsalicylic Acid
SYNONYM/ACRONYM: Acetaminophen (Acephen, Aceta, Apacet, APAP 500, Aspirin
Free Anacin, Banesin, Cetaphen, Dapa, Datril, Dorcol, Exocrine, FeverALL, Genapap,
Genebs, Halenol, Little Fevers, Liquiprin, Mapap, Myapap, Nortemp, Pain Eze,
Panadol, Paracetamol, Redutemp, Ridenol, Silapap,Tempra,Tylenol,Ty-Pap, Uni-Ace,
Valorin); Acetylsalicylic acid (salicylate, aspirin, Anacin, Aspergum, Bufferin,
Easprin, Ecotrin, Empirin, Measurin, Synalgos, ZORprin, ASA).

COMMON USE: To assist in monitoring therapeutic drug levels and detect toxic
levels of acetaminophen and salicylate in suspected overdose and drug abuse.

SPECIMEN: Serum (1 mL) collected in a red-top tube.

NORMAL FINDINGS: (Method: Immunoassay)

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A
70

Monograph_A_047-079.indd 70
Therapeutic
Range
Conventional Conversion to Volume of Protein
Drug Units SI units SI Units Half-Life Distribution Binding Excretion
Acetaminophen 520 mcg/mL SI units = 33132 13 hr 0.95 L/kg 20%50% 85%95% hepatic;
Conventional micromol/L metabolites, renal
Units 6.62
Salicylate 1030 mg/dL SI units = 0.72.2 23 hr 0.10.3 L/kg 90%95% 1 hepatic; metabolites,
Conventional mmol/L renal
Units 0.073
Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

17/11/14 12:04 PM
Analgesic, Anti-inflammatory, and Antipyretic Drugs 71

IMPORTANT NOTE: These medications


DESCRIPTION: Acetaminophen is are metabolized and excreted by the
used for headache, fever, and pain liver and kidneys and are therefore
relief, especially for individuals contraindicated in patients with hepat- A
unable to take salicylate products ic or renal disease and cautiously
or who have bleeding conditions. advised in patients with renal impair-
It is the analgesic of choice for ment. Information regarding medica-
children less than 13 yr old; salicy- tion must be clearly and accurately
lates are avoided in this age group communicated to avoid misunder-
because of the association standing of the dose time in relation to
between aspirin and Reyes syn- the collection time. Miscommunication
drome. Acetaminophen is rapidly between the individual administering
absorbed from the gastrointestinal the medication and the individual col-
tract and reaches peak concentra- lecting the specimen is the most fre-
tion within 30 to 60 min after quent cause of subtherapeutic levels,
administration of a therapeutic toxic levels, and misleading informa-
dose. It can be a silent killer tion used in calculation of future doses.
because, by the time symptoms of If administration of the drug is delayed,
intoxication appear 24 to 48 hr notify the appropriate department(s)
after ingestion, the antidote is to reschedule the blood draw and
ineffective. Acetylsalicylic acid notify the requesting health-care pro-
(ASA) is also used for headache, vider (HCP) if the delay has caused any
fever, inflammation, and real or perceived therapeutic harm.
pain relief. Some patients with
cardiovascular disease take small This procedure is
prophylactic doses. The main site contraindicated for: N/A
of toxicity for both drugs is the
liver, particularly in the presence INDICATIONS
of liver disease or decreased drug Suspected overdose
metabolism and excretion. Other Suspected toxicity
medications indicated for use in Therapeutic monitoring
controlling neuropathic pain
include amitriptyline and nortrip-
tyline. Detailed information is POTENTIAL DIAGNOSIS
found in the monograph titled Increased in
Antidepressant Drugs (Cyclic): Acetaminophen
Amitriptyline, Nortriptyline, Alcoholic cirrhosis (related to inability of
Protriptyline, Doxepin, damaged liver to metabolize the drug)
Imipramine, Desipramine. Liver disease (related to inability of
Many factors must be consid- damaged liver to metabolize the drug)
ered in interpreting drug levels, Toxicity
including patient age, patient ASA
weight, interacting medications, Toxicity
electrolyte balance, protein levels,
water balance, conditions that Decreased in
affect absorption and excretion, Noncompliance with therapeutic
and the ingestion of substances regimen
(e.g., foods, herbals, vitamins,
and minerals) that can potentiate CRITICAL FINDINGS
or inhibit the intended target Note: The adverse effects of subthera-
concentration. peutic levels are also important. Care
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72 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

should be taken to investigate signs renal function. In stage III (72 to 96 hr


and symptoms of too little and too after ingestion), signs and symptoms
much medication. Note and immedi- may include nausea, vomiting, jaun-
A ately report to the requesting HCP dice, confusion, coagulation disorders,
any critically increased or subthera- continued elevation of AST and ALT,
peutic values and related symptoms. decreased renal function, and coma.
It is essential that a critical find- Intervention may include gastrointes-
ing be communicated immediately tinal decontamination (stomach pum
to the requesting HCP. A listing of ping) if the patient presents within 6
these findings varies among facilities. hr of ingestion or administration of
Timely notification of a critical N-acetylcysteine (Mucomyst) in the
finding for lab or diagnostic studies is case of an acute intoxication in which
a role expectation of the professional the patient presents more than 6 hr
nurse. The notification processes will after ingestion.
vary among facilities. Upon receipt of
the critical finding the information ASA: Greater Than 40 mg/dL:
should be read back to the caller to (SI Greater Than 2.9 mmol/L)
verify accuracy. Most policies require Signs and symptoms of salicylate
immediate notification of the primary intoxication include ketosis, convul-
HCP, hospitalist, or on-call HCP. sions, dizziness, nausea, vomiting,
Reported information includes the hyperactivity, hyperglycemia, hyper-
patients name, unique identifiers, crit- pnea, hyperthermia, respiratory
ical finding, name of the person giving arrest, and tinnitus. Possible interven-
the report, and name of the person tions include administration of acti-
receiving the report. Documentation vated charcoal as vomiting ceases,
of notification should be made in the alkalinization of the urine with bicar-
medical record with the name of the bonate, and a single dose of vitamin K
HCP notified, time and date of notifi- (for rare instances of hypoprothrom-
cation, and any orders received. Any binemia).
delay in a timely report of a critical
finding may require completion of a
notification form with review by Risk INTERFERING FACTORS
Management. Blood drawn in serum separator
tubes (gel tubes).
Acetaminophen: Greater Than Drugs that may increase acetamin-
200 mcg/mL (4 hr postingestion): ophen levels include diflunisal,
(SI Greater Than 1,324 micromol/L metoclopramide, and probenecid.
[4 hr postingestion]) Drugs that may decrease acet-
Signs and symptoms of acetamino- aminophen levels include
phen intoxication occur in stages carbamazepine, cholestyramine,
over a period of time. In stage I (0 to iron, oral contraceptives, and
24 hr after ingestion), symptoms may propantheline.
include gastrointestinal irritation, pal- Drugs that increase ASA levels
lor, lethargy, diaphoresis, metabolic include choline magnesium tri-
acidosis, and possibly coma. In stage II salicylate, cimetidine, furosemide,
(24 to 48 hr after ingestion), signs and and sulfinpyrazone.
symptoms may include right upper Drugs and substances that
quadrant abdominal pain; elevated decrease ASA levels include
liver enzymes, aspartate aminotrans- activated charcoal, antacids
ferase (AST), and alanine aminotrans- (aluminum hydroxide), corticoste-
ferase (ALT); and possible decreased roids, and iron.

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Analgesic, Anti-inflammatory, and Antipyretic Drugs 73

Avoid the use of equipment containing


NURSING IMPLICATIONS latex if the patient has a history of aller-
AND PROCEDURE gic reaction to latex.
Instruct the patient to cooperate fully
PRETEST: and to follow directions. Direct the A
Positively identify the patient using at patient to breathe normally and to
least two unique identifiers before avoid unnecessary movement.
providing care, treatment, or services. Observe standard precautions, and
Patient Teaching: Inform the patient this follow the general guidelines in
test can assist with evaluation of how Appendix A. Consider recommended
much medication is in his or her system. collection time in relation to the dosing
Obtain a complete history of the time and schedule. Positively identify the patient,
amount of drug ingested by the patient. and label the appropriate specimen
Obtain a history of the patients container with the corresponding
complaints, including a list of known patient demographics, initials of the
allergens, especially allergies or person collecting the specimen, date,
sensitivities to latex. and time of collection, noting the last
Review results of previously performed dose of medication taken. Perform a
laboratory tests and diagnostic and venipuncture.
surgical procedures. Remove the needle and apply direct
Obtain a history of the patients geni- pressure with dry gauze to stop
tourinary and hepatobiliary systems, the bleeding. Observe/assess the
symptoms, and results of previously venipuncture site for bleeding and
performed laboratory tests and diag- hematoma formation and secure gauze
nostic and surgical procedures. These with adhesive bandage.
medications are metabolized and Promptly transport the specimen to
excreted by the kidneys and liver. the laboratory for processing and
Obtain a list of the patients current analysis.
medications, including herbs, nutri-
tional supplements, and nutraceuticals POST-TEST:
(see Appendix H online at DavisPlus).
Inform the patient that a report of the
Review the procedure with the
results will be made available to the
patient. Inform the patient that
requesting HCP, who will discuss the
specimen collection takes approxi-
results with the patient.
mately 5 to 10 min. Address concerns
Nutritional Considerations: Include avoid-
about pain and explain that there may
ance of alcohol consumption.
be some discomfort during the
Reinforce information given by the
venipuncture.
patients HCP regarding further testing,
Sensitivity to social and cultural issues,
treatment, or referral to another HCP.
as well as concern for modesty, is
Explain to the patient the importance
important in providing psychological
of following the medication regimen
support before, during, and after the
and instructions regarding food and
procedure.
drug interactions. Answer any ques-
Note that there are no food, fluid, or
tions or address any concerns voiced
medication restrictions unless by medi-
by the patient or family.
cal direction.
Recognize anxiety related to test
INTRATEST: results, and explain to the patient
the importance of following the
Potential Complications: medication regimen and instructions
Lack of consideration for the proper regarding food and drug interactions.
collection time relative to the dosing Instruct the patient to be prepared
schedule can provide misleading infor- to provide the pharmacist with a list
mation that may result in erroneous of other medications he or she is
interpretation of levels, creating the already taking in the event that the
potential for a medication errorrelated requesting HCP prescribes a
injury to the patient. medication.
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74 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

Depending on the results of this RELATED MONOGRAPHS:


procedure, additional testing may Related tests include ALT, AST,
be performed to evaluate or monitor bilirubin, biopsy liver, BUN, creatinine,
progression of the disease process
A and determine the need for a change
electrolytes, glucose, lactic acid, aPTT,
and PT/INR.
in therapy. Evaluate test results in See the Genitourinary and Hepatobiliary
relation to the patients symptoms systems tables at the end of the book for
and other tests performed. related tests by body system.

Angiography, Abdomen
SYNONYM/ACRONYM: Abdominal angiogram, abdominal arteriography.

COMMON USE: To visualize and assess abdominal organs/structure for tumor,


infection, or aneurysm.

AREA OF APPLICATION: Abdomen.

CONTRAST: Iodine based.

DESCRIPTION: Abdominal angiogra- A digital image is taken prior to


phy allows x-ray visualization of injection of the contrast and then
the large and small arteries, veins, again after the contrast has been
and associated branches of the injected. By subtracting the prein-
abdominal vasculature and organ jection image from the postinjec-
parenchyma after contrast medi- tion image, a higher-quality, unob-
um injection. This visualization is structed image can be created.
accomplished by the injection of Patterns of circulation, organ
contrast medium through a cathe- function, and changes in vessel
ter, which most commonly has wall appearance can be viewed to
been inserted into the femoral help diagnose the presence of
artery and advanced through the vascular abnormalities, aneurysm,
iliac artery and aorta into the tumor, trauma, or lesions. The
organ-specific artery. Fluoroscopy catheter used to administer the
is used to guide catheter place- contrast medium to confirm the
ment, and angiograms (high-speed diagnosis of organ lesions may be
x-ray images) provide images of used to deliver chemotherapeutic
the organ of interest and drugs or different types of
associated vessels that are dis- materials administered to stop
played on a monitor and are bleeding. Catheters with attached
recorded for future viewing and inflatable balloons for angioplasty
evaluation. Digital subtraction and wire mesh stents are used to
angiography (DSA) is a computer- widen areas of stenosis and to
ized method of removing unde- keep vessels open, frequently
sired structures, like bone, from replacing surgery. Embolotherapy
the surrounding area of interest. can also be accomplished through

Monograph_A_047-079.indd 74 17/11/14 12:04 PM


Angiography, Abdomen 75

ate to severe reactions to ionic


the same catheter when the site contrast medium.
of bleeding or extravasation is Conditions associated with
located. Angiography is one of the
definitive tests for organ disease
preexisting renal insufficiency A
(e.g., renal failure, single kidney
and may be used to evaluate transplant, nephrectomy, diabetes,
chronic disease and organ failure, multiple myeloma, treatment with
treat arterial stenosis, differentiate aminoglycocides and NSAIDs)
a vascular cyst from hypervascu- because iodinated contrast is
lar cancers, and evaluate the effec- nephrotoxic.
tiveness of medical or surgical Elderly and compromised
treatment. patients who are chronically
dehydrated before the test because
This procedure is of their risk of contrast-induced
contraindicated for renal failure.
Patients who are pregnant or Patients with pheochromocy-
suspected of being pregnant, toma, because iodinated con-
unless the potential benefits of a trast may cause a hypertensive
procedure using radiation far out- crisis.
weigh the risk of radiation expo- Patients with bleeding disor-
sure to the fetus and mother. ders or receiving anticoagulant
Conditions associated with therapy because the puncture site
adverse reactions to contrast may not stop bleeding.
medium (e.g., asthma, food aller-
gies, or allergy to contrast medi- INDICATIONS
um). Although patients are still Aid in angioplasty, atherectomy, or
asked specifically if they have a stent placement
known allergy to iodine or shell- Allow infusion of thrombolytic
fish (shellfish contain high levels drugs into an occluded artery
of iodine), it has been well estab- Detect arterial occlusion, which
lished that the reaction is not to may be evidenced by a transection
iodine; an actual iodine allergy of the artery caused by trauma or
would be very problematic penetrating injury
because iodine is required for the Detect artery stenosis, evidenced
production of thyroid hormones. by vessel dilation, collateral vessels,
In the case of shellfish the reac- or increased vascular pressure
tion is to a muscle protein called Detect nonmalignant tumors before
tropomyosin; in the case of iodin- surgical resection
ated contrast medium the reaction Detect thrombosis, arteriovenous
is to the noniodinated part of the fistula, aneurysms, or emboli in
contrast molecule. Patients with a abdominal vessels
known hypersensitivity to the Detect tumors and arterial supply,
medium may benefit from premed- extent of venous invasion, and
ication with corticosteroids and tumor vascularity
diphenhydramine; the use of non- Detect peripheral artery disease
ionic contrast or an alternative (PAD)
noncontrast imaging study, if avail- Differentiate between tumors and
able, may be considered for cysts
patients who have severe asthma Evaluate organ transplantation for
or who have experienced moder- function or organ rejection

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76 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

Evaluate placement of a shunt or A listing of these findings varies among


stent facilities.
Evaluate tumor vascularity before Timely notification of a critical
A surgery or embolization finding for lab or diagnostic studies is
Evaluate the vascular system of a role expectation of the professional
prospective organ donors before nurse. The notification processes
surgery will vary among facilities. Upon
receipt of the critical finding the
information should be read back to
POTENTIAL DIAGNOSIS
the caller to verify accuracy. Most
Normal findings in policies require immediate notifica-
Normal structure, function, and tion of the primary HCP, hospitalist, or
patency of abdominal organ on-call HCP. Reported information
vessels includes the patients name, unique
Contrast medium normally circulates identifiers, critical finding, name of
throughout abdomen symmetrically the person giving the report, and
and without interruption name of the person receiving
No evidence of obstruction, the report. Documentation of notifi-
variations in number and size cation should be made in the medical
of vessels, malformations, cysts, record with the name of the HCP
or tumors notified, time and date of notification,
and any orders received. Any delay in
Abnormal findings in
a timely report of a critical finding
Abscess or inflammation as seen by
may require completion of a notifica-
edema in the area of the vessel
tion form with review by Risk
Arterial aneurysm visualized by a
Management.
bulging in a vessel
Arterial stenosis, dysplasia, or organ
infarction indicated by a narrowing INTERFERING FACTORS
or blocked artery
Factors that may impair
Arteriovenous fistula or other
clear imaging
abnormalities
Gas or feces in the gastrointestinal
Congenital anomalies
tract resulting from inadequate
Cysts visualized by areas with a
cleansing or failure to restrict food
halo of contrast surrounding them
intake before the study.
or tumors indicated by areas of
Retained barium from a previous
increased density due to the
radiological procedure.
vascularity which collects the
Metallic objects within the exami-
contrast
nation field (e.g., jewelry, body
PAD
rings), which may inhibit organ
Trauma causing tears or other
visualization and can produce
disruption indicated by blood out-
unclear images.
side the vessel
Inability of the patient to cooperate
or remain still during the proce-
CRITICAL FINDINGS dure because of age, significant
Abscess pain, or mental status.
Aneurysm
Other considerations
It is essential that critical findings be Consultation with an HCP should
communicated immediately to the occur before the procedure for
requesting health-care provider (HCP). radiation safety concerns regarding

Monograph_A_047-079.indd 76 17/11/14 12:04 PM


Angiography, Abdomen 77

younger patients or patients who prior to the procedure; a creatinine


are lactating. Pediatric & Geriatric level is also needed before contrast
Imaging Children and geriatric medium is to be used.
Note any recent procedures that can
patients are at risk for receiving a
interfere with test results, including A
higher radiation dose than neces- examinations using iodine-based con-
sary if settings are not adjusted for trast medium or barium. Ensure that
their small size. Pediatric Imaging barium studies were performed more
Information on the Image Gently than 4 days before angiography.
Campaign can be found at the Record the date of the last menstrual
Alliance for Radiation Safety in period and determine the possibility
Pediatric Imaging (www.pedrad of pregnancy in perimenopausal
.org/associations/5364/ig/). women.
Risks associated with radiation Obtain a list of the patients current
medications, including anticoagulants,
overexposure can result from fre- aspirin and other salicylates, herbs,
quent x-ray procedures. Personnel nutritional supplements, and nutraceu-
in the room with the patient ticals, especially those known to affect
should wear a protective lead coagulation (see Appendix H online at
apron, stand behind a shield, or DavisPlus). Such products should be
leave the area while the examina- discontinued by medical direction for
tion is being done. Personnel the appropriate number of days prior
working in the examination area to a surgical procedure. Note the last
should wear badges to record their time and dose of medication taken.
If iodinated contrast medium is
level of radiation exposure. scheduled to be used in patients
Failure to follow dietary restrictions receiving metformin (Glucophage) for
and other pretesting preparations non-insulin-dependent (type 2) diabe-
may cause the procedure to be tes, the drug should be discontinued
canceled or repeated. on the day of the test and continue
to be withheld for 48 hr after the test.
Iodinated contrast can temporarily
impair kidney function, and failure to
withhold metformin may indirectly
NURSING IMPLICATIONS result in drug-induced lactic acidosis,
AND PROCEDURE a dangerous and sometimes fatal
side effect of metformin (related to
PRETEST: renal impairment that does not
Positively identify the patient using at support sufficient excretion of
least two unique identifiers before pro- metformin).
viding care, treatment, or services. Review the procedure with the patient.
Patient Teaching: Inform the patient this Address concerns about pain and
procedure can assist with the evalua- explain that there may be moments of
tion of abdominal organs. discomfort and some pain experi-
Obtain a history of the patients enced during the test. Inform the
complaints or clinical symptoms, patient that the procedure is usually
including a list of known allergens, performed in a radiology or vascular
especially allergies or sensitivities to suite by an HCP and takes approxi-
latex, anesthetics, contrast medium, mately 30 to 60 min.
or sedatives. Sensitivity to social and cultural issues,
Obtain a history of the patients cardio- as well as concern for modesty, is
vascular system, symptoms, and important in providing psychological
results of previously performed labora- support before, during, and after the
tory tests and diagnostic and surgical procedure.
procedures. Ensure results of coagula- Explain that an IV line may be inserted to
tion testing are obtained and recorded allow infusion of IV fluids such as normal

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78 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

saline, anesthetics, sedatives, or emer- injection); or nerve injury or damage


gency medications. Explain that the con- to a nearby organ (which might occur
trast medium will be injected, by cathe- if the catheter strikes a nerve or
ter, at a separate site from the IV line. perforates an organ).
A Inform the patient that a burning and Observe standard precautions, and
flushing sensation may be felt through- follow the general guidelines in
out the body during injection of the Appendix A. Positively identify the
contrast medium. After injection of the patient.
contrast medium, the patient may Ensure the patient has complied with
experience an urge to cough, flushing, dietary and fluid restrictions for 2 to
nausea, or a salty or metallic taste. 4 hr prior to the procedure.
Instruct the patient to remove jewelry Ensure the patient has removed all
and other metallic objects from the external metallic objects from the area
area to be examined. to be examined.
Instruct the patient to fast and restrict Administer ordered prophylactic ste-
fluids for 2 to 4 hr prior to the procedure. roids or antihistamines before the pro-
Protocols may vary among facilities. cedure if the patient has a history of
This procedure may be terminated if allergic reaction to any substance or
chest pain, severe cardiac arrhythmias, drug. Use nonionic contrast medium
or signs of a cerebrovascular accident for the procedure.
occur. Avoid the use of equipment containing
Make sure a written and informed latex if the patient has a history of
consent has been signed prior to the allergic reaction to latex.
procedure and before administering Have emergency equipment readily
any medications. available.
Instruct the patient to void prior to the
INTRATEST: procedure and to change into the gown,
robe, and foot coverings p rovided.
Potential Complications: Instruct the patient to cooperate fully
Establishing an IV site and injection of and to follow directions. Instruct the
contrast medium by catheter are inva- patient to remain still throughout the
sive procedures. Complications are procedure because movement pro-
rare but do include risk for allergic duces unreliable results.
reaction (related to contrast reaction); Record baseline vital signs, and assess
bleeding from the puncture site neurological status. Protocols may vary
(related to a bleeding disorder, or the among facilities.
effects of natural products and medi- Establish an IV fluid line for the injec-
cations known to act as blood thin- tion of saline, sedatives, or emergency
ners; postprocedural bleeding from medications.
the site is rare because at the con- Administer an antianxiety agent, as
clusion of the procedure a resorbable ordered, if the patient has claustropho-
device, composed of non-latex- bia. Administer a sedative to a child or
containing arterial anchor, collagen to an uncooperative adult, as ordered.
plug, and suture, is deployed to seal Place electrocardiographic electrodes
the puncture site); blood clot forma- on the patient for cardiac monitoring.
tion (related to thrombus formation Establish a baseline rhythm; determine
on the tip of the catheter sheath sur- if the patient has ventricular
face or in the lumen of the catheter; arrhythmias.
the use of a heparinized saline flush Using a pen, mark the site of the
during the procedure decreases the patients peripheral pulses before
risk of emboli); hematoma (related to angiography; this allows for quicker
blood leakage into the tissue follow- and more consistent assessment of
ing needle insertion); infection (which the pulses after the procedure.
might occur if bacteria from the skin Place the patient in the supine position
surface is introduced at the puncture on an examination table. Cleanse the
site); tissue damage (related to selected area, and cover with a sterile
extravasation of the contrast during drape.

Monograph_A_047-079.indd 78 17/11/14 12:04 PM


Angiography, Abdomen 79

A local anesthetic is injected at the Assess extremities for signs of isch-


site, and a small incision is made or a emia or absence of distal pulse caused
needle inserted under fluoroscopy. by a catheter-induced thrombus.
The contrast medium is injected, and a Observe/assess the needle/catheter
rapid series of images is taken during insertion site for bleeding, inflamma- A
and after the filling of the vessels to be tion, or hematoma formation.
examined. Delayed images may be Instruct the patient in the care and
taken to examine the vessels after a assessment of the site.
time and to monitor the venous phase Instruct the patient to apply cold
of the procedure. compresses to the puncture site as
Instruct the patient to inhale deeply needed, to reduce discomfort or
and hold his or her breath while the edema.
images are taken, and then to exhale Instruct the patient to maintain bedrest
after the images are taken. for 4 to 6 hr after the procedure or as
Instruct the patient to take slow, deep ordered.
breaths if nausea occurs during the Recognize anxiety related to test
procedure. results, and be supportive of perceived
Monitor the patient for complications loss of independent function. Discuss
related to the procedure (e.g., allergic the implications of abnormal test
reaction, anaphylaxis, bronchospasm). results on the patients lifestyle. Provide
The needle or catheter is removed, teaching and information regarding the
and a pressure dressing is applied over clinical implications of the test results,
the puncture site. as appropriate.
Observe/assess the needle/catheter Reinforce information given by the
insertion site for bleeding, inflamma- patients HCP regarding further test-
tion, or hematoma formation. ing, treatment, or referral to another
HCP. Answer any questions or
POST-TEST: address any concerns voiced by the
Inform the patient that a report of the patient or family. Provide contact
results will be made available to the information, if desired, for the
requesting HCP, who will discuss the American Heart Association (www
results with the patient. .americanheart.org), or the National
Instruct the patient to resume usual Heart, Lung, and Blood Institute
diet, fluids, medications, or activity, as (www.nhlbi.nih.gov), or the Legs for
directed by the HCP. Renal function Life (www.legsforlife.org).
should be assessed before metformin Depending on the results of this pro-
is resumed. cedure, additional testing may be
Monitor vital signs and neurological performed to evaluate or monitor
status every 15 min for 1 hr, then every progression of the disease process
2 hr for 4 hr, and as ordered. Take and determine the need for a change
temperature every 4 hr for 24 hr. in therapy. Evaluate test results in
Monitor intake and output at least every relation to the patients symptoms
8 hr. Compare with baseline values. and other tests performed.
Protocols may vary among facilities.
Observe for delayed allergic reactions, RELATED MONOGRAPHS:
such as rash, urticaria, tachycardia, Related tests include angiography
hyperpnea, hypertension, palpitations, renal, BUN, CT abdomen, CT angio
nausea, or vomiting. graphy, CT brain, CT spleen, CT tho-
Instruct the patient to immediately racic, creatinine, KUB, MRA, MRI
report symptoms such as fast heart abdomen, MRI brain, MRI chest, MRI
rate, difficulty breathing, skin rash, pelvis, aPTT, PT/INR, renogram, US
itching, chest pain, persistent right abdomen, and US lower extremity.
shoulder pain, or abdominal pain. See the Cardiovascular System table
Immediately report symptoms to the at the end of the book for related tests
appropriate HCP. by body system.

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80 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

Angiography, Adrenal
A
SYNONYM/ACRONYM: Adrenal angiogram, adrenal arteriography.

COMMON USE: To visualize and assess the adrenal gland for cancer or other
tumors or masses.

AREA OF APPLICATION: Adrenal gland.

CONTRAST: Iodine based.

DESCRIPTION: Adrenal angiography lesions.This definitive test for adre-


evaluates adrenal dysfunction by nal disease may be used to evaluate
allowing x-ray visualization of the chronic adrenal disease, evaluate
large and small arteries of the adre- arterial or venous stenosis, differen-
nal gland vasculature and paren- tiate an adrenal cyst from adrenal
chyma.This visualization is accom- tumors, identify pheochromocyto-
plished by the injection of contrast ma, and evaluate medical therapy
medium through a catheter that or surgery of the adrenal glands.
has been inserted into the femoral Imaging studies cannot always
artery for viewing the artery (arte- visualize a tumor, especially if it is
riography) or into the femoral vein small. Adrenal venous sampling
for viewing the veins (venography). can be very challenging beginning
Fluoroscopy is used to guide cathe- with proper placement of the
ter placement, and angiograms catheter; after the catheter is in
(high-speed x-ray images) provide place, blood samples may be taken
images of the adrenal glands and from the vein of each gland and
associated vessels surrounding the the distal portion of the vena cava
adrenal tissue which are displayed to assess cortisol and ACTH levels.
on a monitor and are recorded for The information is used to assist in
future viewing and evaluation. determining a diagnosis of ACTH-
Digital subtraction angiography independent Cushings syndrome
(DSA) is a computerized method of (benign or malignant adrenal
removing undesired structures, like growth that secretes cortisol) or
bone, from the surrounding area of primary hyperaldosteronism
interest. A digital image is taken (excessive adrenal gland produc-
prior to injection of the contrast tion of aldosterone). The gold stan-
and then again after the contrast dard for distinguishing between a
has been injected. By subtracting cortisol-secreting tumor and unilat-
the preinjection image from the eral or bilateral adrenal hyperplasia
postinjection image a higher-quali- is considered to be measurement of
ty, unobstructed image can be cre- aldosterone/cortisol ratios taken
ated. Patterns of circulation, adrenal from a series of samples during
function, and changes in vessel adrenal angiography. Cortisol levels
wall appearance can be viewed to will be elevated if related to
help diagnose the presence of Cushings syndrome. A ratio of
vascular abnormalities, trauma, or greater than 4:1 is indicative of

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Angiography, Adrenal 81

Conditions associated with


unilateral hyperplasia. Ratios preexisting renal insufficiency
between each gland are similar and (e.g., renal failure, single kidney
usually less than 3:1 in the presence
of bilateral hyperplasia. Obtaining
transplant, nephrectomy, diabetes, A
multiple myeloma, treatment with
the correct diagnosis from the aminoglycocides and NSAIDs)
angiogram is important because because iodinated contrast is
treatment for adrenal adenoma and nephrotoxic.
unilateral adrenal hyperplasia is sur- Elderly and compromised
gical removal of the affected adrenal patients who are chronically
gland, while bilateral adrenal hyper- dehydrated before the test because
trophy is treated medically. of their risk of contrast-induced
renal failure.
Patients with pheochromocy-
This procedure is toma because iodinated con-
contraindicated for trast may cause a hypertensive
Patients who are pregnant or crisis.
suspected of being pregnant, Patients with bleeding disor-
unless the potential benefits of a ders or receiving anticoagulant
procedure using radiation far therapy because the puncture site
outweigh the risk of radiation may not stop bleeding.
exposure to the fetus and mother.
Conditions associated with
adverse reactions to contrast INDICATIONS
medium (e.g., asthma, food allergies, Assist in the infusion of thrombolyt-
or allergy to contrast medium). ic drugs into an occluded artery
Although patients are still asked Assist with the collection of blood
specifically if they have a known samples from the vein for
allergy to iodine or shellfish (shell- laboratory analysis
fish contain high levels of iodine), it Detect adrenal hyperplasia
has been well established that the Detect and determine the location
reaction is not to iodine; an actual of adrenal tumors evidenced by
iodine allergy would be very prob- arterial supply, extent of venous
lematic because iodine is required invasion, and tumor vascularity
for the production of thyroid hor- Detect arterial occlusion, evidenced
mones. In the case of shellfish the by a transection of the artery
reaction is to a muscle protein caused by trauma or a penetrating
called tropomyosin; in the case of injury
iodinated contrast medium the reac- Detect arterial stenosis, evidenced
tion is to the noniodinated part of by vessel dilation, collateral vessels,
the contrast molecule. Patients with or increased vascular pressure
a known hypersensitivity to the Detect nonmalignant tumors before
medium may benefit from premedi- surgical resection
cation with corticosteroids and Detect thrombosis, arteriovenous fis-
diphenhydramine; the use of non- tula, aneurysms, or emboli in vessels
ionic contrast or an alternative non- Differentiate between adrenal
contrast imaging study, if available, tumors and adrenal cysts
may be considered for patients who Evaluate tumor vascularity before
have severe asthma or who have surgery or embolization
experienced moderate to severe Perform angioplasty, perform
reactions to ionic contrast medium. atherectomy, or place a stent
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82 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

POTENTIAL DIAGNOSIS radiation dose than necessary if


settings are not adjusted for their
Normal findings in
small size. Pediatric Imaging
Normal structure, function, and
A patency of adrenal vessels
Information on the Image Gently
Campaign can be found at the
Contrast medium circulating
Alliance for Radiation Safety in
throughout the adrenal gland
Pediatric Imaging (www.pedrad.org/
symmetrically and without
associations/5364/ig/).
interruption
Risks associated with radiation
No evidence of obstruction, varia-
overexposure can result from fre-
tions in number and size of vessels
quent x-ray procedures. Personnel
and organs, malformations, cysts, or
in the examination room with the
tumors
patient should wear a protective
lead apron, stand behind a shield,
Abnormal findings in
or leave the area while the exami-
Adrenal adenoma
nation is being done. Personnel
Adrenal carcinoma
working in the examination area
Bilateral adrenal hyperplasia
should wear badges to record their
Pheochromocytoma
level of radiation exposure.
Failure to follow dietary restrictions
CRITICAL FINDINGS: N/A and other pretesting preparations
may cause the procedure to be
INTERFERING FACTORS canceled or repeated.
Factors that may impair
clear imaging
Gas or feces in the gastrointestinal NURSING IMPLICATIONS
tract resulting from inadequate AND PROCEDURE
cleansing or failure to restrict food PRETEST:
intake before the study. Positively identify the patient using at
Retained barium from a previous least two unique identifiers before pro-
radiological procedure. viding care, treatment, or services.
Metallic objects within the exami- Patient Teaching: Inform the patient
nation field (e.g., jewelry, body this procedure can assist with
rings), which may inhibit organ evaluation of the adrenal gland
visualization and can produce (located near the kidney).
unclear images. Obtain a history of the patients com-
plaints or clinical symptoms, including
Inability of the patient to cooperate a list of known allergens, especially
or remain still during the proce- allergies or sensitivities to latex, anes-
dure because of age, significant thetics, contrast medium, or sedatives.
pain, or mental status. Obtain a history of the patients endo-
crine system, symptoms, and results of
Other considerations previously performed laboratory tests
Consultation with a health-care pro- and diagnostic and surgical procedures.
vider (HCP) should occur before Ensure results of coagulation testing are
the procedure for radiation safety obtained and recorded prior to the pro-
cedure; a creatinine level is also needed
concerns regarding younger before contrast medium is to be used.
patients or patients who are lactat- Note any recent procedures that can
ing. Pediatric & Geriatric Imaging interfere with test results, including
Children and geriatric patients examinations using iodine-based
are at risk for receiving a higher contrast medium or barium. Ensure

Monograph_A_080-110.indd 82 17/11/14 12:04 PM


Angiography, Adrenal 83

that barium studies were performed Instruct the patient to remove jewelry
more than 4 days before angiography. and other metallic objects from the
Record the date of the last menstrual area to be examined.
period and determine the possibility of Instruct the patient to fast and restrict
pregnancy in perimenopausal women. fluids for 2 to 4 hr prior to the procedure. A
Obtain a list of the patients current med- Protocols may vary among facilities.
ications, including anticoagulants, aspirin This procedure may be terminated if
and other salicylates, herbs, nutritional chest pain, severe cardiac arrhythmias, or
supplements, and nutraceuticals, espe- signs of a cerebrovascular accident occur.
cially those known to affect coagulation Make sure a written and informed
(see Appendix H online at DavisPlus). consent has been signed prior to the
Such products should be discontinued procedure and before administering
by medical direction for the appropriate any medications.
number of days prior to a surgical proce-
dure. Note the last time and dose of INTRATEST:
medication taken.
If iodinated contrast medium is sched- Potential Complications:
uled to be used in patients receiving Establishing an IV site and injection of
metformin (Glucophage) for non- contrast medium by catheter are invasive
insulin-dependent (type 2) diabetes, procedures. Complications are rare but
the drug should be discontinued on do include risk for allergic reaction
the day of the test and continue to be (related to contrast reaction); bleeding
withheld for 48 hr after the test. from the puncture site (related to a
Iodinated contrast can temporarily bleeding disorder, or the effects of nat-
impair kidney function, and failure to ural products and medications known
withhold metformin may indirectly to act as blood thinners; postproce-
result in drug-induced lactic acidosis, a dural bleeding from the site is rare
dangerous and sometimes fatal side because at the conclusion of the proce-
effect of metformin (related to renal dure a resorbable device, composed of
impairment that does not support non-latex-containing arterial anchor,
sufficient excretion of metformin). collagen plug, and suture, is deployed
Review the procedure with the patient. to seal the puncture site); blood clot for-
Address concerns about pain and mation (related to thrombus formation
explain that there may be moments of on the tip of the catheter sheath sur-
discomfort and some pain experienced face or in the lumen of the catheter, but
during the test. Inform the patient that the use of a heparinized saline flush
the procedure is usually performed in a during the procedure decreases the
radiology or vascular suite by an HCP risk of emboli); hematoma (related to
and takes approximately 30 to 60 min. blood leakage into the tissue following
Sensitivity to social and cultural issues,as needle insertion); infection (which might
well as concern for modesty, is impor- occur if bacteria from the skin surface
tant in providing psychological support is introduced at the puncture site); tis-
before, during, and after the procedure. sue damage (related to extravasation of
Explain that an IV line may be inserted to the contrast during injection); or nerve
allow infusion of IV fluids such as normal injury or damage to a nearby organ
saline, anesthetics, sedatives, or emer- (which might occur if the catheter
gency medications. Explain that the strikes a nerve or perforates an organ).
contrast medium will be injected, by cath- Avoid the use of equipment containing
eter, at a separate site from the IV line. latex if the patient has a history of
Inform the patient that a burning and allergic reaction to latex.
flushing sensation may be felt through- Observe standard precautions, and
out the body during injection of the follow the general guidelines in Appendix
contrast medium. After injection of the A. Positively identify the patient.
contrast medium, the patient may Ensure the patient has complied with
experience an urge to cough, flushing, dietary, fluid, and medication restric-
nausea, or a salty or metallic taste. tions and pretesting preparations.

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84 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

Ensure the patient has removed all x-ray images are taken, and then to
external metallic objects from the area exhale after the images are taken.
to be examined. Instruct the patient to take slow, deep
Administer ordered prophylactic ste- breaths if nausea occurs during the
A roids or antihistamines before the pro- procedure.
cedure. Use nonionic contrast medium Monitor the patient for complications
for the procedure if the patient has a related to the procedure (e.g., allergic
history of allergic reactions to any reaction, anaphylaxis, bronchospasm).
substance or drug. The needle or catheter is removed,
Have emergency equipment readily and a pressure dressing is applied over
available. the puncture site.
Instruct the patient to void prior to the Observe/assess the needle/catheter
procedure and to change into the gown, insertion site for bleeding, inflamma-
robe, and foot coverings provided. tion, or hematoma formation.
Instruct the patient to cooperate fully
and to follow directions. Instruct the POST-TEST:
patient to remain still throughout the Inform the patient that a report of the
procedure because movement results will be made available to the
produces unreliable results. requesting HCP, who will discuss the
Record baseline vital signs, and continue results with the patient.
to monitor throughout the procedure. Instruct the patient to resume usual diet,
Protocols may vary among facilities. fluids, medications, or activity, as directed
Establish an IV fluid line for the injec- by the HCP. Renal function should be
tion of saline, sedatives, or emergency assessed before metformin is resumed.
medications. Monitor vital signs and neurological sta-
Administer an antianxiety agent, as tus every 15 min for 1 hr, then every
ordered, if the patient has claustropho- 2 hr for 4 hr, and as ordered. Take
bia. Administer a sedative to a child or temperature every 4 hr for 24 hr.
to an uncooperative adult, as ordered. Monitor intake and output at least every
Place electrocardiographic electrodes 8 hr. Compare with baseline values.
on the patient for cardiac monitoring. Protocols may vary among facilities.
Establish a baseline rhythm; deter- Observe for delayed allergic reactions,
mine if the patient has ventricular such as rash, urticaria, tachycardia,
arrhythmias. hyperpnea, hypertension, palpitations,
Using a pen, mark the site of the nausea, or vomiting.
patients peripheral pulses before angi- Instruct the patient to immediately
ography; this allows for quicker and report symptoms such as fast heart
more consistent assessment of the rate, difficulty breathing, skin rash,
pulses after the procedure. itching, chest pain, persistent right
Place the patient in the supine posi- shoulder pain, or abdominal pain.
tion on an examination table. Cleanse Immediately report symptoms to the
the selected area, and cover with a appropriate HCP.
sterile drape. Assess extremities for signs of isch-
A local anesthetic is injected at the emia or absence of distal pulse caused
site, and a small incision is made by a catheter-induced thrombus.
or a needle inserted under Observe/assess the needle/catheter
fluoroscopy. insertion site for bleeding, inflamma-
The contrast medium is injected, and a tion, or hematoma formation.
rapid series of images is taken during Instruct the patient in the care and
and after the filling of the vessels to be assessment of the site.
examined. Delayed images may be Instruct the patient to apply cold com-
taken to examine the vessels after a presses to the puncture site as needed,
time and to monitor the venous phase to reduce discomfort or edema.
of the procedure. Instruct the patient to maintain bed
Instruct the patient to inhale deeply rest for 4 to 6 hr after the procedure or
and hold his or her breath while the as ordered.

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Angiography, Carotid 85

Recognize anxiety related to test progression of the disease process


results, and be supportive of perceived and determine the need for a change
loss of independent function. Discuss in therapy. Evaluate test results in rela-
the implications of abnormal test tion to the patients symptoms and
results on the patients lifestyle. Provide A
other tests performed.
teaching and information regarding the
clinical implications of the test results, RELATED MONOGRAPHS:
as appropriate. Related tests include ACTH and chal-
Reinforce information given by the lenge tests, adrenal gland scan, BUN,
patients HCP regarding further testing, catecholamines, cortisol and challenge
treatment, or referral to another HCP. tests, creatinine, CT abdomen, HVA,
Answer any questions or address any KUB study, metanephrines, MRI abdo-
concerns voiced by the patient or family. men, aPTT, PT/INR, renin, and VMA.
Depending on the results of this Refer to the Endocrine System table at
procedure, additional testing may be the end of the book for related tests by
performed to evaluate or monitor body system.

Angiography, Carotid
SYNONYM/ACRONYM: Carotid angiogram, carotid arteriography.

COMMON USE: To visualize and assess the carotid arteries and surrounding tis-
sues for abscess, tumors, aneurysm, and evaluate for atherosclerotic disease
related to stroke risk.

AREA OF APPLICATION: Neck/cervical area.

CONTRAST: Iodine based.

DESCRIPTION: This test evaluates sired structures, like bone, from


blood vessels in the neck carrying the surrounding area of interest.
arterial blood to the brain and is A digital image is taken prior to
accomplished by the injection of injection of the contrast and then
contrast material through a cathe- again after the contrast has been
ter that has been inserted into the injected. By subtracting the prein-
femoral artery. Fluoroscopy is used jection image from the postinjec-
to guide catheter placement and tion image a higher-quality,
angiograms (high-speed x-ray unobstructed image can be creat-
images) provide images of the ed. The x-ray equipment is mount-
carotid artery and associated ves- ed on a C-shaped arm with the
sels in surrounding tissue which x-ray device beneath the table on
are displayed on a monitor and which the patient lies. Over the
are recorded for future viewing patient is an image intensifier that
and evaluation. Digital subtraction receives the x-rays after they pass
angiography (DSA) is a computer- through the patient. Patterns of cir-
ized method of removing unde- culation or changes in vessel wall

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86 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

moderate to severe reactions to


appearance can be viewed to help ionic contrast medium.
diagnose the presence of vascular Conditions associated with
abnormalities, disease, narrowing,
A enlargement, blockage, trauma, or
preexisting renal insufficiency
(e.g., renal failure, single kidney
lesions. This definitive test for transplant, nephrectomy, diabetes,
arterial disease may be used to multiple myeloma, treatment with
evaluate chronic vascular disease, aminoglycocides and NSAIDs)
arterial or venous stenosis, and because iodinated contrast is
medical therapy or surgery of the nephrotoxic.
vasculature. Catheter angiography Elderly and compromised
still is used in patients who may patients who are chronically
undergo surgery, angioplasty, or dehydrated before the test because
stent placement. of their risk of contrast-induced
renal failure.
Patients with pheochromocy-
This procedure is toma because iodinated con-
contraindicated for trast may cause a hypertensive
Patients who are pregnant or crisis.
suspected of being pregnant, Patients with bleeding disor-
unless the potential benefits of a ders or receiving anticoagulant
procedure using radiation far out- therapy because the puncture site
weigh the risk of radiation expo- may not stop bleeding.
sure to the fetus and mother.
Conditions associated with
adverse reactions to contrast INDICATIONS
medium (e.g., asthma, food allergies, Aid in angioplasty, atherectomy, or
or allergy to contrast medium). stent placement
Although patients are still asked spe- Allow infusion of thrombolytic
cifically if they have a known allergy drugs into an occluded artery
to iodine or shellfish (shellfish con- Detect arterial occlusion, which
tain high levels of iodine), it has may be evidenced by a transection
been well established that the reac- of the artery caused by trauma or
tion is not to iodine; an actual iodine penetrating injury
allergy would be very problematic Detect artery stenosis, evidenced
because iodine is required for the by vessel dilation, collateral vessels,
production of thyroid hormones. In or increased vascular pressure
the case of shellfish the reaction is Detect nonmalignant tumors before
to a muscle protein called tropomy- surgical resection
osin; in the case of iodinated con- Detect tumors and arterial supply,
trast medium the reaction is to the extent of venous invasion, and
noniodinated part of the contrast tumor vascularity
molecule. Patients with a known Detect thrombosis, arteriovenous fis-
hypersensitivity to the medium may tula, aneurysms, or emboli in vessels
benefit from premedication with Evaluate placement of a stent
corticosteroids and diphenhydr- Differentiate between tumors and cysts
amine; the use of nonionic contrast Evaluate tumor vascularity before
or an alternative noncontrast imag- surgery or embolization
ing study, if available, may be consid- Evaluate the vascular system of
ered for patients who have severe prospective organ donors before
asthma or who have experienced surgery

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Angiography, Carotid 87

POTENTIAL DIAGNOSIS concerns regarding younger


patients or patients who are lactat-
Normal findings in
ing. Pediatric & Geriatric
Normal structure, function, and
patency of carotid arteries
Imaging Children and geriatric A
patients are at risk for receiving a
Contrast medium normally
higher radiation dose than neces-
circulates throughout neck
sary if settings are not adjusted for
symmetrically and without
their small size. Pediatric Imaging
interruption
Information on the Image Gently
No evidence of obstruction,
Campaign can be found at the
variations in number and size of
Alliance for Radiation Safety in
vessels, malformations, cysts, or
Pediatric Imaging (www.pedrad
tumors
.org/associations/5364/ig/).
Risks associated with radiation
Abnormal findings in
overexposure can result from fre-
Abscess or inflammation
quent x-ray procedures. Personnel
Arterial stenosis or dysplasia
in the room with the patient
Aneurysms
should wear a protective lead
Arteriovenous fistula or other
apron, stand behind a shield, or
abnormalities
leave the area while the examina-
Congenital anomalies
tion is being done. Personnel work-
Cysts or tumors
ing in the examination area should
Trauma causing tears or other
wear badges to record their level of
disruption
radiation exposure.
Vascular blockage or other disruption
Failure to follow dietary restrictions
and other pretesting preparations
CRITICAL FINDINGS: N/A may cause the procedure to be can-
celed or repeated.
INTERFERING FACTORS
Factors that may impair clear
imaging
NURSING IMPLICATIONS
Gas or feces in the gastrointestinal
AND PROCEDURE
tract resulting from inadequate
cleansing or failure to restrict food PRETEST:
intake before the study. Positively identify the patient using at
Retained barium from a previous least two unique identifiers before pro-
radiological procedure. viding care, treatment, or services.
Metallic objects within the exami- Patient Teaching: Inform the patient this
nation field (e.g., jewelry, body procedure can assist with evaluation of
rings), which may inhibit organ the cardiovascular system.
Obtain a history of the patients com-
visualization and can produce
plaints or clinical symptoms, including
unclear images. a list of known allergens, especially
Inability of the patient to cooperate allergies or sensitivities to latex, anes-
or remain still during the proce- thetics, contrast medium, or sedatives.
dure because of age, significant Obtain a history of the patients cardio-
pain, or mental status. vascular system, symptoms, and
results of previously performed labora-
Other considerations tory tests and diagnostic and surgical
Consultation with a health-care pro- procedures. Ensure results of coagula-
tion testing are obtained and recorded
vider (HCP) should occur before
prior to the procedure; a creatinine
the procedure for radiation safety
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88 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

level is also needed before contrast Inform the patient that a burning and
medium is to be used. flushing sensation may be felt through-
Note any recent procedures that can out the body during injection of the
interfere with test results, including contrast medium. After injection of the
A examinations using iodine-based con- contrast medium, the patient may
trast medium or barium. Ensure that experience an urge to cough, flushing,
barium studies were performed more nausea, or a salty or metallic taste.
than 4 days before angiography. Instruct the patient to remove jewelry
Record the date of the last menstrual and other metallic objects from the
period and determine the possibility of area to be examined.
pregnancy in perimenopausal women. Instruct the patient to fast and restrict
Obtain a list of the patients current fluids for 2 to 4 hr prior to the
medications, including anticoagulants, procedure. Protocols may vary among
aspirin and other salicylates, herbs, facilities.
nutritional supplements, and nutraceu- This procedure may be terminated if
ticals, especially those known to affect chest pain, severe cardiac arrhythmias,
coagulation (see Appendix H online at or signs of a cerebrovascular
DavisPlus). Such products should be accident occur.
discontinued by medical direction for Make sure a written and informed
the appropriate number of days prior consent has been signed prior to the
to a surgical procedure. Note the last procedure and before administering
time and dose of medication taken. any medications.
If iodinated contrast medium is sched-
uled to be used in patients receiving INTRATEST:
metformin (Glucophage) for non-insu- Potential Complications:
lin-dependent (type 2) diabetes, the Establishing an IV site and injection of
drug should be discontinued on the contrast medium by catheter are inva-
day of the test and continue to be sive procedures. Complications are
withheld for 48 hr after the test. rare but do include risk for: allergic
Iodinated contrast can temporarily reaction (related to contrast reac-
impair kidney function, and failure to tion); bleeding from the puncture site
withhold metformin may indirectly (related to a bleeding disorder, or
result in drug-induced lactic acidosis, a the effects of natural products and
dangerous and sometimes fatal side medications known to act as blood
effect of metformin (related to renal thinnerspostprocedural bleeding
impairment that does not support
from the site is rare because at the
etformin).
sufficient excretion of m
conclusion of the procedure a
Review the procedure with the patient. resorbable device, composed of
Address concerns about pain and non-latex-containing arterial anchor,
explain that there may be moments of collagen plug, and suture, is
discomfort and some pain experienced deployed to seal the puncture site);
during the test. Inform the patient that blood clot formation (related to
the procedure is usually performed in a thrombus formation on the tip of the
radiology or vascular suite by an HCP catheter sheath surface or in the
and takes approximately 30 to 60 min. lumen of the catheterthe use of a
Sensitivity to social and cultural issues,as heparinized saline flush during the
well as concern for modesty, is impor- procedure decreases the risk of
tant in providing psychological support emboli); hematoma (related to blood
before, during, and after the procedure. leakage into the tissue following
Explain that an IV line may be inserted needle insertion); infection (that
to allow infusion of IV fluids such as might occur if bacteria from the skin
normal saline, anesthetics, sedatives, surface is introduced at the punc-
or emergency medications. Explain ture site); tissue damage (related to
that the contrast medium will be extravasation of the contrast during
injected, by catheter, at a separate site injection); or nerve injury or damage
from the IV line. to a nearby organ (which might occur

Monograph_A_080-110.indd 88 17/11/14 12:04 PM


Angiography, Carotid 89

if the catheter strikes a nerve or The contrast medium is injected, and a


perforates an organ). rapid series of images is taken during
Avoid the use of equipment containing and after the filling of the vessels to be
latex if the patient has a history of examined. Delayed images may be
allergic reaction to latex. taken to examine the vessels after a A
Observe standard precautions, and fol- time and to monitor the venous phase
low the general guidelines in Appendix of the procedure.
A. Positively identify the patient. Instruct the patient to inhale deeply
Ensure the patient has complied with and hold his or her breath while the
dietary, fluid, and medication restric- images are taken, and then to exhale
tions and pretesting preparations. after the images are taken.
Ensure the patient has removed all Instruct the patient to take slow, deep
external metallic objects from the area breaths if nausea occurs during the
to be examined. procedure.
Administer ordered prophylactic ste- Monitor the patient for complications
roids or antihistamines before the pro- related to the procedure (e.g., allergic
cedure. Use nonionic contrast medium reaction, anaphylaxis, bronchospasm).
for the procedure if the patient has a The needle or catheter is removed,
history of allergic reactions to any sus- and a pressure dressing is applied over
bstance or drug. the puncture site.
Have emergency equipment readily Observe/assess the needle/catheter
available. insertion site for bleeding, inflamma-
Instruct the patient to void prior to the tion, or hematoma formation.
procedure and to change into the gown,
robe, and foot coverings provided. POST-TEST:
Instruct the patient to cooperate fully Inform the patient that a report of the
and to follow directions. Instruct the results will be made available to the
patient to remain still throughout the requesting HCP, who will discuss the
procedure because movement pro- results with the patient.
duces unreliable results. Instruct the patient to resume usual
Record baseline vital signs, and assess diet, fluids, medications, or activity, as
neurological status. Protocols may vary directed by the HCP. Renal function
among facilities. should be assessed before metformin
Establish an IV fluid line for the injec- is resumed.
tion of saline, sedatives, or emergency Monitor vital signs and neurological sta-
medications. tus every 15 min for 1 hr, then every 2 hr
Administer an antianxiety agent, as for 4 hr, and as ordered. Take tempera-
ordered, if the patient has claustropho- ture every 4 hr for 24 hr. Monitor intake
bia. Administer a sedative to a child or and output at least every 8 hr. Compare
to an uncooperative adult, as ordered. with baseline values. Protocols may vary
Place electrocardiographic electrodes from facility to facility.
on the patient for cardiac monitoring. Observe for delayed allergic reactions,
Establish a baseline rhythm; determine such as rash, urticaria, tachycardia,
if the patient has ventricular a
rrhythmias. hyperpnea, hypertension, palpitations,
Using a pen, mark the site of the nausea, or vomiting.
patients peripheral pulses before angi- Instruct the patient to immediately
ography; this allows for quicker and report symptoms such as fast heart
more consistent assessment of the rate, difficulty breathing, skin rash, itch-
pulses after the procedure. ing, chest pain, persistent right shoul-
Place the patient in the supine position der pain, or abdominal pain.
on an examination table. Cleanse the Immediately report symptoms to the
selected area, and cover with a sterile appropriate HCP.
drape. Assess extremities for signs of
A local anesthetic is injected at the site, ischemia or absence of distal pulse
and a small incision is made caused by a catheter-induced
or a needle is inserted under fluoroscopy. thrombus.

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90 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

Observe/assess the needle/catheter importance of adhering to the therapy


insertion site for bleeding, inflamma- regimen. As appropriate, instruct the
tion, or hematoma formation. patient in significant side effects and
Instruct the patient in the care and systemic reactions associated with the
A assessment of the site. prescribed medication. Encourage him
Instruct the patient to apply cold com- or her to review corresponding litera-
presses to the puncture site as needed, ture provided by a pharmacist.
to reduce discomfort or edema. Depending on the results of this
Instruct the patient to maintain bedrest procedure, additional testing may be
for 4 to 6 hr after the procedure or as performed to evaluate or monitor pro-
ordered. gression of the disease process and
Recognize anxiety related to test determine the need for a change in
results, and be supportive of perceived therapy. Evaluate test results in relation
loss of independent function. Discuss to the patients symptoms and other
the implications of abnormal test tests performed.
results on the patients lifestyle. Provide
teaching and information regarding the RELATED MONOGRAPHS:
clinical implications of the test results, Related tests include angiography
as appropriate. abdomen, BUN, CT angiography, CT
Reinforce information given by the brain, creatinine, ECG, exercise
patients HCP regarding further test- stress test, MRA, MRI brain, PT/INR,
ing, treatment, or referral to another plethysmography, US arterial Doppler
HCP. Answer any questions or lower extremities, and US peripheral
address any concerns voiced by the Doppler.
patient or family. See the Cardiovascular System table
Instruct the patient in the use of any at the end of the book for related tests
ordered medications. Explain the by body system.

Angiography, Coronary
SYNONYM/ACRONYM: Angiography of heart, angiocardiography, cardiac angiogra-
phy, cardiac catheterization, cineangiocardiography, coronary angiography,
coronary arteriography.

COMMON USE: To visualize and assess the heart and surrounding structure for
abnormalities, defects, aneurysm, and tumors.

AREA OF APPLICATION: Heart.

CONTRAST: Intravenous or intra-arterial iodine based.

DESCRIPTION: Angiography allows arteries after injection of contrast


x-ray visualization of the heart, medium. Contrast medium is
aorta, inferior vena cava, pulmo- injected through a catheter, which
nary artery and vein, and coronary has been inserted into a peripheral

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Angiography, Coronary 91

vein, usually the femoral or brachial in conjunction with less invasive


vein, for a right heart catheteriza- interventional alternatives to
tion or into an artery, usually the CABG surgery such as percutane-
femoral or brachial artery, for a left ous transluminal coronary angio- A
heart catheterization; through the plasty (PTCA), with or without
same catheter cardiac pressures placement of stents. PTCA is also
and volumes are recorded. known as balloon angioplasty
Fluoroscopy is used to guide cathe- because once the blockage is
ter placement, and angiograms identified and determined to be
(high-speed x-ray images) provide treatable, a balloon catheter is
images of the heart and associated used to help correct the problem.
vessels which are displayed on a The balloon in the catheter is
monitor and are recorded for future inflated to compress the plaque
viewing and evaluation. Digital sub- against the sides of the affected
traction angiography (DSA) is a vessel. The balloon may be
computerized method of removing inflated multiple times and with
undesired structures, like bone, increasing size to increase the
from the surrounding area of inter- diameter of the vessels lumen
est. A digital image is taken prior to which restores more normal
injection of the contrast and then blood flow. A stent, which is a
again after the contrast has been small mesh tube, may be placed
injected. By subtracting the prein- in the affected vessel to keep it
jection image from the postinjec- open after the angioplasty is
tion image a higher-quality, unob- completed.
structed image can be created. Carotid endarterectomy (CEA)
Patterns of circulation, cardiac out- is another procedure that can be
put, cardiac functions, and changes combined with coronary angiog-
in vessel wall appearance can be raphy and may also be part of the
viewed to help diagnose the pres- PTCA procedure. CEA is performed
ence of vascular abnormalities or to reduce stroke risk. Stroke results
lesions. Pulmonary artery abnormal- from severe stenosis of the carotid
ities are seen with right heart arteries and release of plaque embo-
views, and coronary artery and tho- li that travel to the brain, block circu-
racic aorta abnormalities are seen lation, and cause brain tissue death.
with left heart views. Coronary The CEA procedure involves inser-
angiography is useful for evaluating tion of an additional, separate cath-
cardiovascular disease and various eter to insert a device that removes
types of cardiac abnormalities. plaque from the walls of the carotid
Coronary angiography, more arteries.The devices commonly
commonly called cardiac catheter- used to perform CEA employ very
ization, is a definitive test for cor- small drills or rotating blades to
onary artery disease (CAD). CAD remove the plaque. Balloon angio-
is a condition where the blood plasty, with or without stent place-
vessels to the heart lose their elas- ment, usually follows CEA.
ticity and become narrowed by Applications of Cardiac
atheroslerotic deposits of plaque. Catheterization for Infants
Significant blockage is treatable and Pediatric Patients Cardiac
using coronary artery bypass catheterization is very useful in
grafting (CABG) surgery. Cardiac identification of the type of heart
catheterization can also be used defect, determination of the exact

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92 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

the contrast molecule. Patients


location of the defect, and indica- with a known hypersensitivity to
tions regarding the severity of the the medium may benefit from
defect. Some of the common oper-
A able heart defects in infants and
premedication with corticosteroids
and diphenhydramine; the use of
children include repairs for ven- nonionic contrast or an alternative
tricular septal defects, atrial septic noncontrast imaging study, if avail-
defects, tetrology of Fallot, valve able, may be considered for patients
defects, and arterial switches. who have severe asthma or who
Cardiac catheterization can also be have experienced moderate to
used as a palliative procedure severe reactions to ionic contrast
prior to arterial switch repair. The medium.
catheterization, called a balloon Conditions associated with
atrial septostomy, is used to create preexisting renal insufficiency
a small hole in the inner wall of (e.g., renal failure, single kidney
the heart between the atria that transplant, nephrectomy, diabetes,
allows a greater volume of oxygen- multiple myeloma, treatment with
ated blood to enter the circulatory aminoglycocides and NSAIDs)
system. The improved quality of because iodinated contrast is
circulating blood provides some nephrotoxic.
time for very young patients to Elderly and compromised
gain strength prior to the surgical patients who are chronically
repair. The hole is closed when the dehydrated before the test because
corrective surgery is completed. of their risk of contrast-induced
renal failure.
This procedure is Patients with pheochromocy-
contraindicated for toma, because iodinated con-
Patients who are pregnant or trast may cause a hypertensive
suspected of being pregnant, crisis.
unless the potential benefits of a Patients with bleeding disor-
procedure using radiation far out- ders or receiving anticoagulant
weigh the risk of radiation expo- therapy because the puncture site
sure to the fetus and mother. may not stop bleeding.
Conditions associated with
adverse reactions to contrast INDICATIONS
medium (e.g., asthma, food aller- Allow infusion of thrombolytic
gies, or allergy to contrast medium). drugs into an occluded coronary
Although patients are still asked spe- Detect narrowing of coronary ves-
cifically if they have a known aller- sels or abnormalities of the great
gy to iodine or shellfish (shellfish vessels in patients with angina, syn-
contain high levels of iodine), it has cope, abnormal electrocardiogram,
been well established that the reac- hypercholesteremia with chest
tion is not to iodine; an actual pain, and persistent chest pain after
iodine allergy would be very prob- revascularization
lematic because iodine is required Evaluate cardiac muscle function
for the production of thyroid hor- Evaluate cardiac valvular and septal
mones. In the case of shellfish the defects
reaction is to a muscle protein Evaluate disease associated with
called tropomyosin; in the case of the aortic arch
iodinated contrast medium the reac- Evaluate previous cardiac surgery
tion is to the noniodinated part of or other interventional procedures

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Angiography, Coronary 93

Evaluate peripheral artery disease (PAD) POTENTIAL DIAGNOSIS


Evaluate peripheral vascular disease
Normal findings in
(PVD)
Normal great vessels and coronary
Evaluate ventricular aneurysms A
arteries
Monitor pulmonary pressures and
cardiac output
Normal Adult Hemodynamic
Perform angioplasty, perform ather-
Pressures and Volumes Monitored
ectomy, or place a stent
During Coronary Angiography
Quantify the severity of atherosclerot-
(Cardiac Catheterization)
ic, occlusive coronary artery disease

Description of What Measured


Pressures Parameter Represents Normal Value
Arterial blood The pressure in the brachial artery; one Systolic
pressure (also of the significant vital signs, it reflects (100140) mm
known as the pressure the heart exerts to pump Hg/diastolic
routine blood blood through the circulatory system. (6090) mm Hg
pressure)
Mean arterial The average arterial pressure of one 70105 mm Hg
pressure cardiac cycle; considered a better
indicator of perfusion than routine
blood pressure but only obtainable by
direct measurement during cardiac
catheterization.
Left ventricular Peak pressure in the left ventricle Systolic (90140)
pressures during systole/Peak pressure in the mm Hg/diastolic
left ventricle at the end of diastole; (412) mm Hg
indication of contractility of the heart
muscle.
Central venous The right-sided ventricular pressures 26 mm Hg
pressure (right exerted by the central veins closest to
atrial pressure) the heart (jugular, subclavian, or
femoral); used to estimate blood
volume and venous return.
Pulmonary The pressures in the pulmonary artery Systolic (1530)
artery mm Hg/
pressure diastolic
(412) mm Hg
Pulmonary The pressure in the pulmonary vessels; 412 mm Hg
artery wedge used to provide an estimate of left
pressure atrial filling pressure, to provide an
estimate of left ventricle pressure
during end diastole, and a way to
measure ventricular preload.
Volumes
Cardiac output The amount of blood pumped out by 48 L/min
the ventricle of the heart in 1 min

(table continues on page 94)

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94 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

Description of What Measured


Pressures Parameter Represents Normal Value
A Cardiac index The cardiac output adjusted for body 2.54 L/min/m2
surface to provide the index which is
a more precise measurement; used to
assess the function of the ventricle.
Arterial oxygen The concentration of oxygen in the 95100%
saturation blood.
Stroke volume The amount of blood pumped by each 60100 mL/beat
ventricle with each time it contracts in
a heartbeat.
Stroke volume The stroke volume adjusted for body 3357 mL/m2
index surface to provide the index which is
a more precise measurement.
End diastolic The amount of blood in the left ventricle 100160 mL
volume (EDV) at the end of diastole.
EDV index EDV adjusted for body surface to 5080 mL/m2
provide the index which is a more
precise measurement.
End systolic The amount of blood in the left ventricle 50100 mL
volume (ESV) at the end of systole.
ESV index ESV adjusted for body surface to 2550 mL/m2
provide the index which is a more
precise measurement.
Ejection fraction Stroke volume expressed as a 65%
percentage of end diastolic volume.

Abnormal findings in It is essential that critical findings be


Aortic atherosclerosis communicated immediately to the
Aortic dissection requesting health-care provider
Aortitis (HCP). A listing of these findings var-
Aneurysms ies among facilities.
Cardiomyopathy Timely notification of a critical
Congenital anomalies finding for lab or diagnostic studies is
Coronary artery atherosclerosis and a role expectation of the professional
degree of obstruction nurse. The notification processes
Graft occlusion will vary among facilities. Upon
PAD receipt of the critical finding the
PVD information should be read back to
Pulmonary artery abnormalities the caller to verify accuracy. Most
Septal defects policies require immediate notifica-
Trauma causing tears or other tion of the primary HCP, hospitalist, or
disruption on-call HCP. Reported information
Tumors includes the patients name, unique
Valvular disease identifiers, critical finding, name of
the person giving the report, and
CRITICAL FINDINGS name of the person receiving the
Aneurysm report. Documentation of notification
Aortic dissection should be made in the medical record

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Angiography, Coronary 95

with the name of the HCP notified, working in the examination area
time and date of notification, and any should wear badges to record their
orders received. Any delay in a timely level of radiation exposure.
report of a critical finding may require Failure to follow dietary restrictions A
completion of a notification form and other pretesting preparations
with review by Risk Management. may cause the procedure to be can-
celed or repeated.
INTERFERING FACTORS
Factors that may impair clear
imaging NURSING IMPLICATIONS
Gas or feces in the gastrointestinal AND PROCEDURE
tract resulting from inadequate
cleansing or failure to restrict food PRETEST:
intake before the study. Positively identify the patient using
Retained barium from a previous at least two unique identifiers
radiological procedure. before providing care, treatment,
Metallic objects within the exami- or services.
nation field (e.g., jewelry, body Patient Teaching: Inform the patient this
procedure can assist with assessment
rings), which may inhibit organ of cardiac function and check for heart
visualization and can produce disease.
unclear images. Obtain a history of the patients
Inability of the patient to cooperate complaints or clinical symptoms,
or remain still during the proce- including a list of known allergens,
dure because of age, significant especially allergies or sensitivities to
pain, or mental status. latex, anesthetics, contrast medium, or
sedatives.
Other considerations Obtain a history of results of the
patients cardiovascular system, symp-
Consultation with an HCP should toms, and results of previously per-
occur before the procedure for formed laboratory tests and diagnostic
radiation safety concerns regarding and surgical procedures. Ensure
younger patients or patients who results of coagulation testing are
are lactating. Pediatric & Geriatric obtained and recorded prior to the
Imaging Children and geriatric procedure; a creatinine level is also
patients are at risk for receiving a needed before contrast medium is to
higher radiation dose than neces- be used.
sary if settings are not adjusted for Note any recent procedures that can
interfere with test results, including
their small size. Pediatric Imaging examinations using iodine-based con-
Information on the Image Gently trast medium or barium. Ensure that
Campaign can be found at the barium studies were performed more
Alliance for Radiation Safety in than 4 days before angiography.
Pediatric Imaging (www.pedrad Record the date of last menstrual
.org/associations/5364/ig/). period and determine the possibility
Risks associated with radiation of pregnancy in perimenopausal
overexposure can result from women.
frequent x-ray procedures. Obtain a list of the patients current
medications, including anticoagulants,
Personnel in the room with the aspirin and other salicylates, herbs,
patient should wear a protective nutritional supplements, and nutraceu-
lead apron, stand behind a shield, ticals, especially those known to affect
or leave the area while the exami- coagulation (see Appendix H online at
nation is being done. Personnel DavisPlus). Such products should be

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96 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

discontinued by medical direction for Make sure a written and informed


the appropriate number of days prior consent has been signed prior to the
to a surgical procedure. Note the last procedure and before administering
time and dose of medication taken. any medications.
A If iodinated contrast medium is sched-
uled to be used in patients receiving INTRATEST:
metformin (Glucophage) for non-
insulin-dependent (type 2) diabetes, Potential Complications:
the drug should be discontinued on Establishing an IV site and injection of
the day of the test and continue to contrast medium by catheter are invasive
be withheld for 48 hr after the test. procedures. Complications are rare but
Iodinated contrast can temporarily do include risk for: allergic reaction
impair kidney function and failure to (related to contrast reaction); bleeding
withhold metformin may indirectly from the puncture site (related to a
result in drug-induced lactic acidosis, a bleeding disorder, or the effects of nat-
dangerous and sometimes fatal side ural products and medications known
effect of metformin (related to renal to act as blood thinnerspostproce-
impairment that does not support dural bleeding from the site is rare
sufficient excretion of metformin). because at the conclusion of the pro-
Review the procedure with the patient. cedure a resorbable device, composed
Address concerns about pain and of non-latex-containing arterial anchor,
explain that there may be moments of collagen plug, and suture, is deployed
discomfort and some pain experienced to seal the puncture site); blood clot for-
during the test. Inform the patient that mation (related to thrombus formation
the procedure is usually performed in a on the tip of the catheter sheath sur-
radiology or vascular suite by an HCP face or in the lumen of the catheter
and takes approximately 30 to 60 min. the use of a heparinized saline flush
Sensitivity to social and cultural issues,as during the procedure decreases the
well as concern for modesty, is risk of emboli); hematoma (related to
important in providing psychological blood leakage into the tissue following
support before, during, and after the needle insertion); infection (which might
procedure. occur if bacteria from the skin surface
Explain that an IV line may be inserted is introduced at the puncture site); tis-
to allow infusion of IV fluids such as sue damage (related to extravasation of
normal saline, anesthetics, sedatives, the contrast during injection); or nerve
or emergency medications. Explain injury or damage to a nearby organ
that the contrast medium will be (which might occur if the catheter
injected, by catheter, at a separate site strikes a nerve or perforates an organ).
from the IV line. Observe standard precautions, and fol-
Inform the patient that a burning and low the general guidelines in Appendix A.
flushing sensation may be felt through- Positively identify the patient.
out the body during injection of the Ensure the patient has complied with
contrast medium. After injection of the dietary and fluid restrictions for 2 to
contrast medium, the patient may 4 hr prior to the procedure.
experience an urge to cough, flushing, Ensure that the patient has removed
nausea, or a salty or metallic taste. external metallic objects from the area
Instruct the patient to remove jewelry to be examined prior to the procedure.
and other metallic objects from the Administer ordered prophylactic ste-
area to be examined. roids or antihistamines before the pro-
Instruct the patient to fast and restrict cedure. Use nonionic contrast medium
fluids for 2 to 4 hr prior to the procedure. for the procedure if the patient has a
Protocols may vary among facilities. history of allergic reactions to any sub-
This procedure may be terminated if stance or drug.
chest pain, severe cardiac arrhythmias, Avoid the use of equipment containing
or signs of a cerebrovascular latex if the patient has a history of aller-
accident occur. gic reaction to latex.

Monograph_A_080-110.indd 96 17/11/14 12:04 PM


Angiography, Coronary 97

Have emergency equipment readily The needle or catheter is removed,


available. and a pressure dressing is applied over
Instruct the patient to void prior to the the puncture site.
procedure and to change into the gown, Observe/assess the needle/catheter
robe, and foot coverings p rovided. insertion site for bleeding, inflamma- A
Instruct the patient to cooperate fully tion, or hematoma formation.
and to follow directions. Instruct the
patient to remain still throughout the POST-TEST:
procedure because movement pro- Inform the patient that a report of the
duces unreliable results. results will be made available to the
Record baseline vital signs, and continue requesting HCP, who will discuss the
to monitor throughout the procedure. results with the patient.
Protocols may vary among facilities. Instruct the patient to resume usual
Establish an IV fluid line for the injec- diet, fluids, medications, or activity as
tion of saline, sedatives, or emergency directed by the HCP. Renal function
medications. should be assessed before metformin
Administer an antianxiety agent, as is resumed.
ordered, if the patient has claustropho- Monitor vital signs and neurological
bia. Administer a sedative to a child or status every 15 min for 1 hr, then every
to an uncooperative adult, as ordered. 2 hr for 4 hr, and then as ordered by
Place electrocardiographic electrodes the HCP. Take temperature every 4 hr
on the patient for cardiac monitoring. for 24 hr. Monitor intake and output at
Establish a baseline rhythm; determine least every 8 hr. Compare with baseline
if the patient has ventricular values. Protocols may vary from facility
arrhythmias. to facility.
Using a pen, mark the site of the Observe for delayed allergic reactions,
patients peripheral pulses before angi- such as rash, urticaria, tachycardia,
ography; this allows for quicker and hyperpnea, hypertension, palpitations,
more consistent assessment of the nausea, or vomiting.
pulses after the procedure. Instruct the patient to immediately
Place the patient in the supine position report symptoms such as fast heart
on an examination table. Cleanse the rate, difficulty breathing, skin rash, itch-
selected area, and cover with a ing, chest pain, persistent right shoul-
sterile drape. der pain, or abdominal pain.
A local anesthetic is injected at the Immediately report symptoms to the
site, and a small incision is made appropriate HCP.
or a needle is inserted under Assess extremities for signs of
fluoroscopy. ischemia or absence of distal pulse
The contrast medium is injected, and a caused by a catheter-induced
rapid series of images is taken during thrombus.
and after the filling of the vessels to be Observe/assess the needle/catheter
examined. Delayed images may be insertion site for bleeding, inflamma-
taken to examine the vessels after a tion, or hematoma formation.
time and to monitor the venous phase Instruct the patient in the care and
of the procedure. assessment of the site and to observe
Instruct the patient to inhale deeply for bleeding, hematoma formation, bile
and hold his or her breath while the leakage, and inflammation. Any pleu-
x-ray images are taken, and then to ritic pain, persistent right shoulder pain,
exhale after the images are taken. or abdominal pain should be reported
Instruct the patient to take slow, deep to the appropriate HCP.
breaths if nausea occurs during the Instruct the patient to apply cold com-
procedure. presses to the puncture site as needed,
Monitor the patient for complications to reduce discomfort or edema.
related to the procedure (e.g., Instruct the patient to maintain bedrest
allergic reaction, anaphylaxis, for 4 to 6 hr after the procedure or as
bronchospasm). ordered.

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98 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

Nutritional Considerations: Nutritional of the test results, as appropriate.


therapy is recommended for the Provide contact information, if desired,
patient identified to be at risk for devel- for the American Heart Association
oping CAD or for individuals who have (www.americanheart.org), the National
A specific risk factors and/or existing Heart, Lung, and Blood Institute
medical conditions (e.g., elevated LDL (www.nhlbi.nih.gov), and the Legs for
cholesterol levels, other lipid disorders, Life (www.legsforlife.org).
insulin-dependent diabetes, insulin Reinforce information given by the
resistance, or metabolic syndrome). patients HCP regarding further testing,
Other changeable risk factors warrant- treatment, or referral to another HCP.
ing patient education include strategies Answer any questions or address any
to encourage patients, especially those concerns voiced by the patient or family.
who are overweight and with high Instruct the patient in the use of any
blood pressure, to safely decrease ordered medications. Explain the
sodium intake, achieve a normal importance of adhering to the therapy
weight, ensure regular participation of regimen. As appropriate, instruct the
moderate aerobic physical activity patient in significant side effects and
three to four times per week, eliminate systemic reactions associated with the
tobacco use, and adhere to a heart- prescribed medication. Encourage him
healthy diet. If triglycerides also are or her to review corresponding litera-
elevated, the patient should be advised ture provided by a pharmacist.
to eliminate or reduce alcohol. The Depending on the results of this proce-
2013 Guideline on Lifestyle dure, additional testing may be needed
Management to Reduce to evaluate or monitor progression of
Cardiovascular Risk published by the the disease process and determine the
ACC and AHA in conjunction with the need for a change in therapy. Evaluate
NHLBI recommends a test results in relation to the patients
Mediterranean-style diet rather than a symptoms and other tests performed.
low-fat diet. The new guideline empha-
sizes inclusion of vegetables, whole RELATED MONOGRAPHS:
grains, fruits, low-fat dairy, nuts, Related tests include angiography
legumes, and nontropical vegetable carotid, blood pool imaging, BNP,
oils (e.g., olive, canola, peanut, sun- BUN, chest x-ray, cholesterol HDL and
flower, flaxseed) along with fish and LDL, cholesterol total, CT abdomen,
lean poultry. A similar dietary pattern CT angiography, CT biliary tract and
known as the DASH diet makes addi- liver, CT cardiac scoring, CT spleen,
tional recommendations for the reduc- CT thoracic, CK, creatinine, CRP, elec-
tion of dietary sodium. Both dietary trocardiography, electrocardiography
styles emphasize a reduction in con- transesophageal, Holter monitor,
sumption of red meats, which are high homocysteine, lipoprotein electropho-
in saturated fats and cholesterol, and resis, MR angiography, MRI abdomen,
other foods containing sugar, saturated MRI chest, myocardial perfusion heart
fats, trans fats, and sodium. scan, plethysmography, aPTT, PT/INR,
Recognize anxiety related to test triglycerides, troponin, and US arterial
results. Discuss the implications of Doppler carotid.
abnormal test results on the patients Refer to the Cardiovascular System
lifestyle. Provide teaching and informa- table at the end of the book for related
tion regarding the clinical implications tests by body system.

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Angiography, Pulmonary 99

Angiography, Pulmonary A
SYNONYM/ACRONYM: Pulmonary angiography, pulmonary arteriography.

COMMON USE: To visualize and assess the lungs and surrounding structure for
abscess, tumor, cancer, defects, tuberculosis, and pulmonary embolism.

AREA OF APPLICATION: Pulmonary vasculature.

CONTRAST: Intravenous iodine based.

DESCRIPTION: Pulmonary angiogra- venous drainage, and pulmonary


phy allows x-ray visualization of fistulae. Hemodynamic measure-
the pulmonary vasculature after ments during pulmonary angiog-
injection of an iodinated contrast raphy can assist in the diagnosis
medium into the pulmonary of pulmonary hypertension and
artery or a branch of this great cor pulmonale. Pulmonary angio-
vessel. Contrast medium is inject- grams are requested less frequent-
ed through a catheter that has ly in favor of CT pulmonary
been inserted into the vascular angiograms which are less inva-
system, usually through the femo- sive, faster, have fewer complica-
ral or brachial vein. Fluoroscopy is tions, and are of similar quality.
used to guide catheter placement,
and angiograms (high-speed x-ray
images) provide images of the This procedure is
pulmonary vessels which are dis- contraindicated for
played on a monitor and are Patients who are pregnant or
recorded for future viewing and suspected of being pregnant,
evaluation. Digital subtraction unless the potential benefits of a
angiography (DSA) is a computer- procedure using radiation far out-
ized method of removing unde- weigh the risk of radiation expo-
sired structures, like bone, from sure to the fetus and mother.
the surrounding area of interest. A Conditions associated with
digital image is taken prior to adverse reactions to contrast
injection of the contrast and then medium (e.g., asthma, food
again after the contrast has been allergies, or allergy to contrast
injected. By subtracting the prein- medium).
jection image from the postinjec- Although patients are still asked
tion image a higher-quality, unob- specifically if they have a known
structed image can be created. It allergy to iodine or shellfish (shell-
is one of the definitive tests for fish contain high levels of iodine), it
pulmonary embolism, but it is has been well established that the
also useful for evaluating other reaction is not to iodine; an actual
types of pulmonary vascular iodine allergy would be very prob-
abnormalities. It is definitive for lematic because iodine is required
peripheral pulmonary artery ste- for the production of thyroid hor-
nosis, anomalous pulmonary mones. In the case of shellfish the
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100 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

reaction is to a muscle protein POTENTIAL DIAGNOSIS


called tropomyosin; in the case of
Normal findings in
iodinated contrast medium the
Normal pulmonary vasculature;
A reaction is to the noniodinated
radiopaque iodine contrast medium
part of the contrast molecule.
should circulate symmetrically and
Patients with a known hypersensi-
without interruption through the
tivity to the medium may benefit
pulmonary circulatory system.
from premedication with cortico-
steroids and diphenhydramine; the Abnormal findings in
use of nonionic contrast or an Aneurysms
alternative noncontrast imaging Arterial hypoplasia or stenosis
study, if available, may be consid- Arteriovenous malformations
ered for patients who have severe Bleeding caused by tuberculosis,
asthma or who have experienced bronchiectasis, sarcoidosis, or
moderate to severe reactions to aspergilloma
ionic contrast medium. Inflammatory diseases
Conditions associated with Pulmonary embolism (PE) acute or
preexisting renal insufficiency chronic (visualized as an area of
(e.g., renal failure, single kidney interrupted opacity in the pulmo-
transplant, nephrectomy, diabetes, nary artery)
multiple myeloma, treatment with Pulmonary sequestration
aminoglycocides and NSAIDs) Tumors
because iodinated contrast is
nephrotoxic.
Elderly and compromised CRITICAL FINDINGS
patients who are chronically PE
dehydrated before the test because
It is essential that critical findings be
of their risk of contrast-induced
communicated immediately to the
renal failure.
requesting health-care provider
Patients with pheochromocy-
(HCP). A listing of these findings var-
toma because iodinated con-
ies among facilities.
trast may cause a hypertensive
Timely notification of a critical
crisis.
finding for lab or diagnostic studies is
Patients with bleeding disor-
a role expectation of the professional
ders or receiving anticoagulant
nurse. The notification processes will
therapy because the puncture site
vary among facilities. Upon receipt of
may not stop bleeding.
the critical finding the information
should be read back to the caller to
INDICATIONS verify accuracy. Most policies require
Detect acute pulmonary embolism immediate notification of the primary
Detect arteriovenous malforma- HCP, hospitalist, or on-call HCP.
tions or aneurysms Reported information includes the
Detect tumors; aneurysms; patients name, unique identifiers,
congenital defects; vascular chang- critical finding, name of the person
es associated with emphysema, giving the report, and name of the
blebs, and bullae; and heart person receiving the report.
abnormalities Documentation of notification should
Determine the cause of recurrent be made in the medical record with
or severe hemoptysis the name of the HCP notified, time
Evaluate pulmonary circulation and date of notification, and any

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Angiography, Pulmonary 101

orders received. Any delay in a timely


report of a critical finding may require NURSING IMPLICATIONS
completion of a notification form AND PROCEDURE
with review by Risk Management. PRETEST: A
Positively identify the patient using at
INTERFERING FACTORS least two unique identifiers before pro-
Factors that may impair clear viding care, treatment, or services.
imaging Patient Teaching: Inform the patient this
procedure can assist with assessment
Retained barium from a previous
of lung function and check for disease.
radiological procedure. Obtain a history of the patients com-
Metallic objects within the exami- plaints or clinical symptoms, including
nation field (e.g., jewelry, body a list of known allergens, especially
rings), which may inhibit organ allergies or sensitivities to latex, anes-
visualization and can produce thetics, contrast medium, or sedatives.
unclear images. Obtain a history of the patients cardio-
Inability of the patient to cooperate vascular and respiratory systems,
or remain still during the proce- symptoms, and results of previously
performed laboratory tests and diag-
dure because of age, significant
nostic and surgical procedures. Ensure
pain, or mental status. results of coagulation testing are
obtained and recorded prior to the pro-
Other considerations cedure; a creatinine level is also needed
Consultation with an HCP should before contrast medium is to be used.
occur before the procedure for Note any recent procedures that can
radiation safety concerns regarding interfere with test results, including
younger patients or patients who examinations using iodine-based con-
are lactating. Pediatric & Geriatric trast medium or barium. Ensure that
barium studies were performed more
Imaging Children and geriatric
than 4 days before angiography.
patients are at risk for receiving a Record the date of the last menstrual
higher radiation dose than neces- period and determine the possibility of
sary if settings are not adjusted for pregnancy in perimenopausal women.
their small size. Pediatric Imaging Obtain a list of the patients current med-
Information on the Image Gently ications, including anticoagulants, aspirin
Campaign can be found at the and other salicylates, herbs, nutritional
Alliance for Radiation Safety in supplements, and nutraceuticals, espe-
Pediatric Imaging (www.pedrad cially those known to affect coagulation
(see Appendix H online at DavisPlus).
.org/associations/5364/ig/).
Such products should be discontinued
Risks associated with radiation over- by medical direction for the appropriate
exposure can result from frequent number of days prior to a surgical proce-
x-ray procedures. Personnel in the dure. Note the last time and dose of
room with the patient should wear a medication taken.
protective lead apron, stand behind a If iodinated contrast medium is sched-
shield, or leave the area while the uled to be used in patients receiving
examination is being done. Personnel metformin (Glucophage) for non-insulin-
working in the examination area dependent (type 2) diabetes, the drug
should be discontinued on the day of
should wear badges to record their
the test and continue to be withheld for
level of radiation exposure. 48 hr after the test. Iodinated contrast
Failure to follow dietary restrictions can temporarily impair kidney function
and other pretesting preparations and failure to withhold metformin may
may cause the procedure to be can- indirectly result in drug-induced lactic
celed or repeated. acidosis, a dangerous and sometimes

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102 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

fatal side effect of metformin (related to collagen plug, and suture, is


renal impairment that does not support deployed to seal the puncture site);
etformin).
sufficient excretion of m blood clot formation (related to throm-
Review the procedure with the patient. bus formation on the tip of the cathe-
A Address concerns about pain and ter sheath surface or in the lumen of
explain that there may be moments of the catheterthe use of a heparin-
discomfort and some pain experienced ized saline flush during the procedure
during the test. Inform the patient that decreases the risk of emboli); hema-
the procedure is usually performed in a toma (related to blood leakage into the
radiology or vascular suite by an HCP tissue following insertion of the cathe-
and takes approximately 30 to 60 min. ter); infection (which might occur if
Sensitivity to social and cultural issues,as bacteria from the skin surface is intro-
well as concern for modesty, is impor- duced during catheter insertion); tissue
tant in providing psychological support damage (related to extravasation of the
before, during, and after the procedure. contrast during injection); or nerve
Explain that an IV line may be inserted injury or damage to a nearby organ
to allow infusion of IV fluids such as (which might occur if the catheter
normal saline, anesthetics, sedatives, strikes a nerve or perforates an organ).
or emergency medications. Explain Observe standard precautions, and fol-
that the contrast medium will be low the general guidelines in Appendix A.
injected, by catheter, at a separate site Positively identify the patient.
from the IV line. Ensure the patient has complied with
Inform the patient that a burning and dietary, fluid, and medication restric-
flushing sensation may be felt through- tions and pretesting preparations for
out the body during injection of the 2 to 4 hr prior to the procedure.
contrast medium. After injection of the Ensure the patient has removed all
contrast medium, the patient may external metallic objects from the area
experience an urge to cough, flushing, to be examined.
nausea, or a salty or metallic taste. Administer ordered prophylactic ste-
Instruct the patient to remove jewelry roids or antihistamines before the pro-
and other metallic objects from the cedure. Use nonionic contrast medium
area to be examined. for the procedure if the patient has a
Instruct the patient to fast and restrict history of allergic reactions to any sub-
fluids for 2 to 4 hr prior to the p rocedure. stance or drug.
Protocols may vary among facilities. Avoid the use of equipment containing
This procedure may be terminated if latex if the patient has a history of aller-
chest pain, severe cardiac arrhythmias, or gic reaction to latex.
signs of a cerebrovascular accident occur. Have emergency equipment readily
Make sure a written and informed available.
consent has been signed prior to the Instruct the patient to void prior to the
procedure and before administering procedure and to change into the gown,
any medications. robe, and foot coverings p rovided.
Instruct the patient to cooperate fully
INTRATEST:
and to follow directions. Instruct the
Potential Complications: patient to remain still throughout the
Injection of the contrast by inserting a procedure because movement pro-
catheter into a blood vessel is an inva- duces unreliable results.
sive procedure. Complications are rare Record baseline vital signs, and continue
but do include risk for: allergic reaction to monitor throughout the procedure.
(related to contrast reaction); bleed- Protocols may vary among facilities.
ing (related to perforation of the Establish an IV fluid line for the injec-
blood vesselpostprocedural bleed- tion of saline, sedatives, or emergency
ing from the site is rare because at medications.
the conclusion of the procedure a Administer an antianxiety agent,
resorbable device, composed of non- as ordered, if the patient has
latex-containing arterial anchor, claustrophobia. Administer a sedative

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Angiography, Pulmonary 103

to a child or to an uncooperative adult, hyperpnea, hypertension, palpitations,


as ordered. nausea, or vomiting.
Place electrocardiographic electrodes on Instruct the patient to immediately
the patient for cardiac monitoring. report symptoms such as fast heart
Establish a baseline rhythm; determine if rate, difficulty breathing, skin rash, A
the patient has ventricular arrhythmias. itching, chest pain, persistent right
Using a pen, mark the site of the shoulder pain, or abdominal pain.
patients peripheral pulses before angi- Immediately report symptoms to the
ography; this allows for quicker and appropriate HCP.
more consistent assessment of the Assess extremities for signs of isch-
pulses after the procedure. emia or absence of distal pulse caused
Place the patient in the supine position on by a catheter-induced thrombus.
an examination table. Cleanse the selected Observe/assess the needle/catheter
area, and cover with a sterile drape. insertion site for bleeding, inflamma-
A local anesthetic is injected at the tion, or hematoma formation.
site, and a small incision is made or a Instruct the patient in the care and
needle is inserted under fluoroscopy. assessment of the site.
The contrast medium is injected, and a Instruct the patient to apply cold com-
rapid series of images is taken during presses to the puncture site as needed,
and after the filling of the vessels to be to reduce discomfort or edema.
examined. Instruct the patient to maintain bedrest
Instruct the patient to inhale deeply for 4 to 6 hr after the procedure or as
and hold his or her breath while the ordered.
images are taken, and then to exhale Recognize anxiety related to test results,
after the images are taken. and be supportive of perceived loss of
Instruct the patient to take slow, deep independent function. Discuss the impli-
breaths if nausea occurs during the cations of abnormal test results on the
procedure. patients lifestyle. Provide teaching and
Monitor the patient for complications information regarding the clinical implica-
related to the procedure (e.g., allergic tions of the test results, as appropriate.
reaction, anaphylaxis, bronchospasm). Reinforce information given by the
The needle or catheter is removed, patients HCP regarding further testing,
and a pressure dressing is applied over treatment, or referral to another HCP.
the puncture site. Answer any questions or address any
Observe/assess the needle/catheter concerns voiced by the patient or family.
insertion site for bleeding, inflamma- Depending on the results of this
tion, or hematoma formation. procedure, additional testing may be
performed to evaluate or monitor pro-
POST-TEST: gression of the disease process and
Inform the patient that a report of the determine the need for a change in
results will be made available to the therapy. Evaluate test results in relation
requesting HCP, who will discuss the to the patients symptoms and other
results with the patient. tests performed.
Instruct the patient to resume usual diet,
fluids, medications, or activity, as directed RELATED MONOGRAPHS:
by the HCP. Renal function should be Related tests include alveolar/arterial
assessed before metformin is resumed. gradient, blood gases, BNP, BUN,
Monitor vital signs and neurological sta- chest x-ray, creatinine, CT angiography,
tus every 15 min for 1 hr, then every 2 hr CT thoracic, ECG, FDP, lactic acid, lung
for 4 hr, and as ordered. Take the tem- perfusion scan, lung ventilation scan,
perature every 4 hr for 24 hr. Monitor MRA, MRI chest, MRI venography,
intake and output at least every 8 hr. aPTT, and PT/INR.
Compare with baseline values. Protocols Refer to the Cardiovascular and
may vary from facility to facility. Respiratory systems tables at the
Observe for delayed allergic reactions, end of the book for related tests by
such as rash, urticaria, tachycardia, body system.

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104 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

Angiography, Renal
A
SYNONYM/ACRONYM: Renal angiogram, renal arteriography.

COMMON USE: To visualize and assess the kidneys and surrounding structure for
tumor, cancer, absent kidney, and level of renal disease.

AREA OF APPLICATION: Kidney.

CONTRAST: Intra-arterial iodine based.

DESCRIPTION: Renal angiography test for renal disease may be used


allows x-ray visualization of the to evaluate chronic renal disease,
large and small arteries of the renal failure, and renal artery ste-
renal vasculature and parenchyma nosis; differentiate a vascular renal
or the renal veins and their cyst from hypervascular renal can-
branches. Contrast medium is cers; and evaluate renal transplant
injected through a catheter that donors, recipients, and the kidney
has been inserted into the femoral after transplantation.
artery or vein and advanced
through the iliac artery and aorta
into the renal artery or the inferi- This procedure is
or vena cava into the renal vein. contraindicated for
Fluoroscopy is used to guide cath- Patients who are pregnant or
eter placement, and angiograms suspected of being pregnant,
(high-speed x-ray images) provide unless the potential benefits of a
images of the kidneys and associ- procedure using radiation far out-
ated vessels which are displayed weigh the risk of radiation expo-
on a monitor and are recorded for sure to the fetus and mother.
future viewing and evaluation. Conditions associated with
Digital subtraction angiography adverse reactions to contrast
(DSA) is a computerized method medium (e.g., asthma, food allergies,
of removing undesired structures, or allergy to contrast medium).
like bone, from the surrounding Although patients are still asked spe-
area of interest. A digital image is cifically if they have a known allergy
taken prior to injection of the to iodine or shellfish (shellfish con-
contrast and then again after the tain high levels of iodine), it has been
contrast has been injected. By sub- well established that the reaction is
tracting the preinjection image not to iodine; an actual iodine allergy
from the postinjection image a would be very problematic because
higher-quality, unobstructed image iodine is required for the production
can be created. Patterns of circula- of thyroid hormones. In the case of
tion, renal function, or changes in shellfish the reaction is to a muscle
vessel wall appearance can be protein called tropomyosin; in the
viewed to help diagnose the pres- case of iodinated contrast medium
ence of vascular abnormalities, the reaction is to the noniodinated
trauma, or lesions. This definitive part of the contrast molecule.

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Angiography, Renal 105

Conditions associated with Evaluate placement of a stent


preexisting renal insufficiency Evaluate postoperative renal
(e.g., renal failure, single kidney transplantation for function or organ
transplant, nephrectomy, diabetes, rejection A
multiple myeloma, treatment with Evaluate renal function in chronic
aminoglycocides and NSAIDs) renal failure or end-stage renal
because iodinated contrast is disease or hydronephrosis
nephrotoxic. Evaluate the renal vascular system
Elderly and compromised of prospective kidney donors
patients who are chronically before surgery
dehydrated before the test because Evaluate tumor vascularity before
of their risk of contrast-induced surgery or embolization
renal failure.
Patients with pheochromocy-
POTENTIAL DIAGNOSIS
toma because iodinated con-
trast may cause a hypertensive Normal findings in
crisis. Normal structure, function, and
Patients with bleeding disor- patency of renal vessels
ders receiving an arterial or Contrast medium circulating
venous puncture because the site throughout the kidneys symmetri-
may not stop bleeding. cally and without interruption
No evidence of obstruction, varia-
tions in number and size of vessels
INDICATIONS and organs, malformations, cysts, or
Aid in angioplasty, atherectomy, or tumors
stent placement
Allow infusion of thrombolytic Abnormal findings in
drugs into an occluded artery Abscess or inflammation
Assist with the collection of blood Arterial stenosis, dysplasia, or
samples from renal vein for renin infarction
analysis Arteriovenous fistula or other
Detect arterial occlusion as evi- abnormalities
denced by a transection of the Congenital anomalies
renal artery caused by trauma or a Intrarenal hematoma
penetrating injury Renal artery aneurysm
Detect nonmalignant tumors before Renal cysts or tumors
surgical resection Trauma causing tears or other
Detect renal artery stenosis as evi- disruption
denced by vessel dilation, collateral
vessels, or increased renovascular
CRITICAL FINDINGS: N/A
pressure
Detect renal tumors as evidenced
INTERFERING FACTORS
by arterial supply, extent of venous
invasion, and tumor vascularity Factors that may impair clear
Detect small kidney or absence of a imaging
kidney Gas or feces in the gastrointestinal
Detect thrombosis, arteriovenous tract resulting from inadequate
fistulae, aneurysms, or emboli in cleansing or failure to restrict food
renal vessels intake before the study.
Differentiate between renal tumors Retained barium from a previous
and renal cysts radiological procedure.
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106 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

Metallic objects within the exami- kidney function and check for
nation field (e.g., jewelry, body disease.
rings), which may inhibit organ Obtain a history of the patients com-
plaints or clinical symptoms, including
A visualization and can produce
a list of known allergens, especially
unclear images. allergies or sensitivities to latex, anes-
Inability of the patient to cooperate thetics, contrast medium, or sedatives.
or remain still during the proce- Obtain a history of the patients genito-
dure because of age, significant urinary system, symptoms, and results
pain, or mental status. of previously performed laboratory
tests and diagnostic and surgical pro-
Other considerations cedures. Ensure results of coagulation
Consultation with a health-care pro- testing are obtained and recorded prior
vider (HCP) should occur before the to the procedure; a creatinine level is
also needed before contrast medium is
procedure for radiation safety con- to be used.
cerns regarding younger patients or Note any recent procedures that can
patients who are lactating. Pediatric interfere with test results, including
& Geriatric Imaging Children and examinations using iodine-based con-
geriatric patients are at risk for trast medium or barium. Ensure that
receiving a higher radiation dose barium studies were performed more
than necessary if settings are not than 4 days before angiography.
adjusted for their small size. Record the date of the last menstrual
Pediatric Imaging Information on period and determine the possibility of
pregnancy in perimenopausal women.
the Image Gently Campaign can be Obtain a list of the patients current
found at the Alliance for Radiation medications, including anticoagulants,
Safety in Pediatric Imaging (www aspirin and other salicylates, herbs,
.pedrad.org/associations/5364/ig/). nutritional supplements, and nutraceu-
Risks associated with radiation over- ticals (see Appendix H online at
exposure can result from frequent DavisPlus). Such products should be
x-ray procedures. Personnel in the discontinued by medical direction for
room with the patient should wear a the appropriate number of days prior
protective lead apron, stand behind a to a surgical procedure. Note the last
time and dose of medication taken.
shield, or leave the area while the If iodinated contrast medium is sched-
examination is being done. Personnel uled to be used in patients receiving
working in the examination area metformin (Glucophage) for non-insulin-
should wear badges to record their dependent (type 2) diabetes, the drug
level of radiation exposure. should be discontinued on the day of
Failure to follow dietary restrictions the test and continue to be withheld for
and other pretesting preparations 48 hr after the test. Iodinated contrast
may cause the procedure to be can- can temporarily impair kidney function,
celed or repeated. and failure to withhold metformin may
indirectly result in drug-induced lactic
acidosis, a dangerous and sometimes
fatal side effect of metformin (related
NURSING IMPLICATIONS to renal impairment that does not
AND PROCEDURE support sufficient excretion of
metformin).
PRETEST: Review the procedure with the patient.
Positively identify the patient using at Address concerns about pain and
least two unique identifiers before pro- explain that there may be moments of
viding care, treatment, or services. discomfort and some pain experienced
Patient Teaching: Inform the patient this during the test. Inform the patient that
procedure can assist in assessment of the procedure is usually performed in a

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Angiography, Renal 107

radiology or vascular suite by an HCP during the procedure decreases the


and takes approximately 30 to 60 min. risk of emboli); hematoma (related to
Sensitivity to social and cultural issues,as blood leakage into the tissue follow-
well as concern for modesty, is impor- ing needle insertion); infection (which
tant in providing psychological support might occur if bacteria from the skin A
before, during, and after the procedure. surface is introduced at the puncture
Explain that an IV line may be inserted to site); tissue damage (related to
allow infusion of IV fluids such as normal extravasation of the contrast during
saline, anesthetics, sedatives, or emer- injection); or nerve injury or damage to
gency medications. Explain that the con- a nearby organ (which might occur if
trast medium will be injected, by cathe- the catheter strikes a nerve or perfo-
ter, at a separate site from the IV line. rates an organ).
Inform the patient that a burning and Observe standard precautions, and fol-
flushing sensation may be felt through- low the general guidelines in Appendix A.
out the body during injection of the Positively identify the patient.
contrast medium. After injection of the Ensure the patient has complied with
contrast medium, the patient may dietary, fluid, and medication restrictions
experience an urge to cough, flushing, for 2 to 4 hr prior to the procedure.
nausea, or a salty or metallic taste. Ensure the patient has removed all
Instruct the patient to remove jewelry, external metallic objects from the area
and other metallic objects from the to be examined.
area to be examined. Administer ordered prophylactic ste-
Instruct the patient to fast and restrict roids or antihistamines before the pro-
fluids for 2 to 4 hr prior to the procedure. cedure. Use nonionic contrast medium
Protocols may vary among facilities. for the procedure if the patient has a
This procedure may be terminated if history of allergic reactions to any sub-
chest pain, severe cardiac arrhythmias, or stance or drug.
signs of a cerebrovascular accident occur. Avoid the use of equipment containing
Make sure a written and informed latex if the patient has a history of aller-
consent has been signed prior to the gic reaction to latex.
procedure and before administering Have emergency equipment readily
any medications. available.
Instruct the patient to void prior to the
INTRATEST: procedure and to change into the gown,
robe, and foot coverings provided.
Potential Complications: Instruct the patient to cooperate fully
Establishing an IV site and injection of and to follow directions. Instruct the
contrast medium by catheter are inva- patient to remain still throughout the
sive procedures. Complications are procedure because movement pro-
rare but do include risk for allergic duces unreliable results.
reaction (related to contrast reaction); Record baseline vital signs, and continue
bleeding from the puncture site (related to monitor throughout the procedure.
to a bleeding disorder, or the effects Protocols may vary among facilities.
of natural products and medications Establish an IV fluid line for the injec-
known to act as blood thinners tion of saline, sedatives, or emergency
postprocedural bleeding from the site medications.
is rare because at the conclusion of Administer an antianxiety agent, as
the procedure a resorbable device, ordered, if the patient has claustropho-
composed of non-latex-containing bia. Administer a sedative to a child or
arterial anchor, collagen plug, and to an uncooperative adult, as ordered.
suture, is deployed to seal the Place electrocardiographic electrodes on
puncture site); blood clot formation the patient for cardiac monitoring.
(related to thrombus formation on Establish a baseline rhythm; determine if
the tip of the catheter sheath surface the patient has ventricular arrhythmias.
or in the lumen of the catheter Using a pen, mark the site of the
the use of a heparinized saline flush patients peripheral pulses before

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108 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

angiography; this allows for quicker Instruct the patient to immediately


and more consistent assessment of report symptoms such as fast heart
the pulses after the procedure. rate, difficulty breathing, skin rash,
Place the patient in the supine position on itching, chest pain, persistent right
A an examination table. Cleanse the selected shoulder pain, or abdominal pain.
area, and cover with a sterile drape. Immediately report symptoms to the
A local anesthetic is injected at the appropriate HCP.
site, and a small incision is made or a Assess extremities for signs of isch-
needle is inserted under fluoroscopy. emia or absence of distal pulse caused
The contrast medium is injected, and a by a catheter-induced thrombus.
rapid series of images is taken during Observe/assess the needle/catheter
and after the filling of the vessels to be insertion site for bleeding, inflamma-
examined. Delayed images may be tion, or hematoma formation.
taken to examine the vessels after a Instruct the patient in the care and
time and to monitor the venous phase assessment of the site.
of the procedure. Instruct the patient to apply cold com-
Instruct the patient to inhale deeply presses to the puncture site as
and hold his or her breath while the needed, to reduce discomfort or
images are taken, and then to exhale edema.
after the images are taken. Instruct the patient to maintain bedrest
Instruct the patient to take slow, deep for 4 to 6 hr after the procedure or as
breaths if nausea occurs during the ordered.
procedure. Recognize anxiety related to test
Monitor the patient for complications results, and be supportive of perceived
related to the procedure (e.g., allergic loss of independent function. Discuss
reaction, anaphylaxis, bronchospasm). the implications of abnormal test
The needle or catheter is removed, results on the patients lifestyle. Provide
and a pressure dressing is applied over teaching and information regarding the
the puncture site. clinical implications of the test results,
Observe/assess the needle/catheter as appropriate.
insertion site for bleeding, inflamma- Reinforce information given by the
tion, or hematoma formation. patients HCP regarding further testing,
treatment, or referral to another HCP.
POST-TEST: Answer any questions or address
Inform the patient that a report of the any concerns voiced by the patient
results will be made available to the or family.
requesting HCP, who will discuss the Depending on the results of this proce-
results with the patient. dure, additional testing may be needed
Instruct the patient to resume usual to evaluate or monitor progression of
diet, fluids, medications, or activity, as the disease process and determine the
directed by the HCP. Renal function need for a change in therapy. Evaluate
should be assessed before metformin test results in relation to the patients
is resumed. symptoms and other tests performed.
Monitor vital signs and neurological sta-
tus every 15 min for 1 hr, then every RELATED MONOGRAPHS:
2 hr for 4 hr, and as ordered. Take Related tests include biopsy kidney,
temperature every 4 hr for 24 hr. BUN, creatinine, CT abdomen, CT
Monitor intake and output at least every angiography, culture urine, cytology
8 hr. Compare with baseline values. urine, KUB study, IVP, MRA, MRI
Protocols may vary among facilities. abdomen, aPTT, PT/INR, renin,
Observe for delayed allergic reactions, renogram, US kidney, and UA.
such as rash, urticaria, tachycardia, Refer to the Genitourinary System
hyperpnea, hypertension, palpitations, table at the end of the book for related
nausea, or vomiting. tests by body system.

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Angiotensin-Converting Enzyme 109

Angiotensin-Converting Enzyme A
SYNONYM/ACRONYM: Angiotensin Iconverting enzyme (ACE).

COMMON USE: To assist in diagnosing, evaluating treatment, and monitoring the


progression of sarcoidosis, a granulomatous disease that primarily affects the lungs.

SPECIMEN: Serum (1 mL) collected in a gold-, red-, or red/gray-top tube.

NORMAL FINDINGS: (Method: Spectrophotometry)

Age Conventional Units SI Units (Conventional Units 16.667)


02 yr 583 units/L 831383 nKat/L
37 yr 876 units/L 133 1267 nKat/L
814 yr 689 units/L 1001483 nKat/L
Greater than 1268 units/L 2001133 nKat/L
14 yr

This procedure is Hyperthyroidism (untreated) (related


contraindicated for: N/A to possible involvement of thyroid
hormones in regulation of ACE)
POTENTIAL DIAGNOSIS Pulmonary fibrosis (related to
release of ACE from damaged
Increased in
pulmonary tissue)
Bronchitis (acute and chronic)
Rheumatoid arthritis (related to
(related to release of ACE from
development of interstitial lung
damaged pulmonary tissue)
disease, pulmonary fibrosis, and
Connective tissue disease (related
release of ACE from damaged
to release of ACE from scarred
pulmonary tissue)
and damaged pulmonary
Sarcoidosis (related to release of ACE
tissue)
from damaged pulmonary tissue)
Gauchers disease (related to
release of ACE from damaged
Decreased in
pulmonary tissue; Gauchers dis-
Advanced pulmonary carcinoma
ease is due to the hereditary
(related to lack of functional
deficiency of an enzyme that
cells to produce ACE)
results in accumulation of a fatty
The period following corticosteroid
substance that damages pulmo-
therapy for sarcoidosis (evidenced
nary tissue)
by cessation of effective therapy)
Hansens disease (leprosy)
Histoplasmosis and other fungal
diseases CRITICAL FINDINGS: N/A
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110 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

Anion Gap
A
SYNONYM/ACRONYM: Agap.

COMMON USE: To assist in diagnosing metabolic disorders that result in meta-


bolic acidosis and electrolyte imbalance such as severe dehydration.

SPECIMEN: Serum (1 mL) for electrolytes collected in a gold-, red-, or red/gray-top


tube. Plasma (1 mL) collected in a green-top (heparin) tube is also acceptable.

NORMAL FINDINGS: (Method: Anion gap is derived mathematically from the


direct measurement of sodium, chloride, and total carbon dioxide.) There are
differences between serum and plasma values for some electrolytes. The refer-
ence ranges listed are based on serum values.

Age Conventional and SI Units


Child or adult 816 mmol/L

This procedure is Chronic vomiting or gastric suction


contraindicated for: N/A (related to alkalosis due to net
loss of acid)
Excess alkali ingestion
POTENTIAL DIAGNOSIS Hypergammaglobulinemia (related
Increased in to an increase in measurable
Metabolic acidosis that results from anions relative to the excessive
the accumulation of unmeasured production of unmeasured
anionic substances like proteins, cationic M proteins)
phosphorus, sulfates, ketoacids, or Hypoalbuminemia (related to
other organic acid waste products of decreased levels of unmeasured
metabolism anionic proteins relative to
stable and measurable cation
Dehydration (severe) concentrations)
Ketoacidosis caused by starvation, Hyponatremia (related to net loss
high-protein/low-carbohydrate of cations)
diet, diabetes, and alcoholism
Lactic acidosis (shock, excessive Significant acidosis or alkalosis can
exercise, some malignancies) result from increased levels of unmea-
Poisoning (salicylate, methanol, sured cations like ionized calcium
ethylene glycol, or paraldehyde) and magnesium or unmeasured
Renal failure anions like proteins, phosphorus, sul-
Uremia fates, or other organic acids, the
effects of which may not be accurately
Decreased in reflected by the calculated anion gap.
Conditions that result in metabolic
alkalosis CRITICAL FINDINGS: N/A
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.com, keyword Van Leeuwen).

Monograph_A_080-110.indd 110 17/11/14 12:04 PM


Antiarrhythmic Drugs 111

Antiarrhythmic Drugs: Amiodarone Digoxin, A


Disopyramide, Flecainide, Lidocaine,
Procainamide, Quinidine
SYNONYM/ACRONYM: Amiodarone (Cordarone); Digoxin (Digitek, Lanoxicaps,
Lanoxin); disopyramide (Norpace, Norpace CR); flecainide (flecainide acetate,
Tambocor); lidocaine (Xylocaine); procainamide (Procanbid, Pronestyl,
Pronestyl SR); quinidine (Quinidex Extentabs, quinidine sulface SR, quinidine
gluconate SR).

COMMON USE: To evaluate specific drugs for subtherapeutic, therapeutic, or


toxic levels in treatment of heart failure and cardiac arrhythmias.

SPECIMEN: Serum (1 mL) collected in a red-top tube.

Route of
Drug Administration Recommended Collection Time
Amiodarone Oral Trough: immediately before next dose
Digoxin Oral Trough: 1224 hr after dose
Never draw peak samples
Disopyramide Oral Trough: immediately before next dose
Peak: 25 hr after dose
Flecainide Oral Trough: immediately before next dose
Peak: 3 hr after dose
Lidocaine IV 15 min, 1 hr, then every 24 hr
Procainamide IV 15 min; 2, 6, 12 hr; then every 24 hr
Procainamide Oral Trough: immediately before next dose
Peak: 75 min after dose
Quinidine sulfate Oral Trough: immediately before next dose
Peak: 1 hr after dose
Quinidine gluconate Oral Trough: immediately before next dose
Peak: 5 hr after dose
Quinidine Oral Trough: immediately before next dose
polygalacturonate Peak: 2 hr after dose

NORMAL FINDINGS: (Method: Immunoassay)

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Monograph_A_111-131.indd 111 17/11/14 12:04 PM


A
Therapeutic Range Volume of
112

Drug Conventional Conversion Distribution Protein


(Indication) Units to SI units SI Units Half-Life (hr) (L/kg) Binding (%) Excretion
Amiodarone 0.52.5 mcg/mL SI units = 0.83.9 2501200 20100 9597 1 hepatic
Conventional micromol/L

Monograph_A_111-131.indd 112
Units 1.55
Digoxin 0.52 ng/mL SI units = 0.62.6 2060 7 2030 1 renal
Conventional nmol/L
Units 1.28
Disopyramide 2.87 mcg/mL SI units = 8.320.6 410 0.70.9 2060 1 renal
Conventional micromol/L
Units 2.95
Flecainide 0.21 mcg/mL SI units = 0.52.4 719 513 4050 1 renal
Conventional micromol/L
Units 2.41
Lidocaine 1.55 mcg/mL SI units = 6.421.4 1.52 11.5 6080 1 hepatic
Conventional micromol/L
Units 4.27
Procainamide 410 mcg/mL SI units = 1742 26 24 1020 1 renal
Conventional micromol/L
Units 4.25
N-acetyl 1020 mcg/mL SI units = 4285 8 1 renal
procainamide Conventional micromol/L
Units 4.25
Quinidine 25 mcg/mL SI units = 615 68 23 7090 Renal and
Conventional micromol/L hepatic
Units 3.08
Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

17/11/14 12:04 PM
Antiarrhythmic Drugs 113

and kidneys and are therefore contra-


DESCRIPTION: Cardiac glycosides indicated in patients with hepatic or
are used in the prophylactic man- renal disease and cautiously advised in
agement and treatment of heart patients with renal impairment. A
failure and ventricular and atrial Information regarding medications
arrhythmias. Because these drugs must be communicated clearly and
have narrow therapeutic windows, accurately to avoid misunderstanding
they must be monitored closely. of the dose time in relation to the
The signs and symptoms of toxici- collection time. Miscommunication
ty are often difficult to distinguish between the individual administering
from those of cardiac disease. the medication and the individual col-
Patients with toxic levels may lecting the specimen is the most fre-
show gastrointestinal, ocular, and quent cause of subtherapeutic levels,
central nervous system effects and toxic levels, and misleading informa-
disturbances in potassium balance. tion used in the calculation of
Many factors must be consid- future doses. If administration of the
ered in effective dosing and moni- drug is delayed, notify the appropriate
toring of therapeutic drugs, includ- department(s) to reschedule the
ing patient age, patient ethnicity, blood draw and notify the requesting
patient weight, interacting medica- health-care provider (HCP) if the delay
tions, electrolyte balance, protein has caused any real or perceived ther-
levels, water balance, conditions apeutic harm.
that affect absorption and excre-
tion, and the ingestion of substanc- This procedure is
es (e.g., foods, herbals, vitamins, and contraindicated for: N/A
minerals) that can either potentiate
or inhibit the intended target con- INDICATIONS
centration. Peak and trough collec- Assist in the diagnosis and preven-
tion times should be documented tion of toxicity
carefully in relation to the time of Monitor compliance with therapeu-
medication administration. tic regimen
Monitor patients who have a pace-
maker, who have impaired renal or
IMPORTANT NOTE: These medications are hepatic function, or who are taking
metabolized and excreted by the liver interacting drugs

POTENTIAL DIAGNOSIS

Level Response
Normal levels Therapeutic effect
Subtherapeutic levels Adjust dose as indicated
Toxic levels Adjust dose as indicated
Amiodarone Hepatic impairment, older results
Digoxin Renal impairment, CHF,* older adults
Disopyramide Renal impairment
Flecainide Renal impairment, CHF
Lidocaine Hepatic impairment, CHF
Procainamide Renal impairment
Quinidine Renal and hepatic impairment, CHF, older adults

*CHF = congestive heart failure.

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114 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

CRITICAL FINDINGS electrocardiographic (ECG) monitor-


Adverse effects of subtherapeutic lev- ing for worsening of arrhythmia.
els are important. Care should be
A taken to investigate the signs and Digoxin: Greater Than 2.5 ng/mL
symptoms of too little and too much (SI: Greater Than 3.2 nmol/L)
medication. Note and immediately Signs and symptoms of digoxin tox-
report to the HCP any critically icity include arrhythmias, anorexia,
increased or subtherapeutic values hyperkalemia, nausea, vomiting, diar-
and related symptoms. rhea, changes in mental status, and
Timely notification of a critical visual disturbances (objects appear
finding for lab or diagnostic studies yellow or have halos around them).
is a role expectation of the profes- Possible interventions include dis-
sional nurse. The notification pro- continuing the medication, continu-
cesses will vary among facilities. ous ECG monitoring (prolonged P-R
Upon receipt of the critical finding interval, widening QRS interval,
the information should be read back lengthening Q-Tc interval, and atrio-
to the caller to verify accuracy. Most ventricular block), transcutaneous
policies require immediate notifica- pacing, administration of activated
tion of the primary HCP, hospitalist, charcoal (if the patient has a gag
or on-call HCP. Reported information reflex and central nervous system
includes the patients name, unique function), support and treatment of
identifiers, critical finding, name of electrolyte disturbance, and adminis-
the person giving the report, and tration of Digibind (digoxin immune
name of the person receiving the Fab). The amount of Digibind given
report. Documentation of notifica- depends on the level of digoxin to
tion should be made in the medical be neutralized. Digoxin levels must
record with the name of the HCP be measured before the administra-
notified, time and date of notifica- tion of Digibind. Digoxin levels
tion, and any orders received. Any should not be measured for several
delay in a timely report of a critical days after administration of Digibind
finding may require completion of a in patients with normal renal func-
notification form with review by tion (1 wk or longer in patients with
Risk Management. decreased renal function). Digibind
cross-reacts in the digoxin assay and
Amiodarone: Greater Than may provide misleading elevations
2.5 mcg/mL (SI: Greater Than or decreases in values depending on
3.9 micromol/L) the particular assay in use by the
Signs and symptoms of pulmonary laboratory.
damage related to amiodarone toxici-
ty include bronchospasm, wheezing, Disopyramide: Greater Than
fever, dyspnea, cough, hemoptysis, 7 mcg/mL (SI: Greater Than
and hypoxia. Possible interventions 20.6 micromol/L)
include discontinuing the medication, Signs and symptoms of disopyra-
monitoring pulmonary function with mide toxicity include prolonged Q-T
chest x-ray, monitoring liver function interval, ventricular tachycardia,
tests to assess for liver damage, hypotension, and heart failure.
monitoring thyroid function tests to Possible interventions include dis-
assess for thyroid damage (related continuing the medication, airway
to the high concentration of iodine support, and ECG and blood pres-
contained in the medication), and sure monitoring.

Monograph_A_111-131.indd 114 17/11/14 12:04 PM


Antiarrhythmic Drugs 115

Flecainide: Greater Than idening of QRS and Q-T intervals),


w
1 mcg/mL (SI: Greater Than asystole, hallucinations, paresthesia,
2.41 micromol/L) and irritability. Possible interventions
Signs and symptoms of flecainide tox- include airway support, emesis, gas- A
icity include exaggerated pharmaco- tric lavage, administration of activated
logical effects resulting in arrhythmia. charcoal, administration of sodium
Possible interventions include discon- lactate, and temporary transcutane-
tinuing the medication as well as ous or transvenous pacemaker.
continuous ECG, respiratory, and
blood pressure monitoring. INTERFERING FACTORS
Blood drawn in serum separator
tubes (gel tubes).
Lidocaine: Greater Than Drugs that may increase amioda-
6 mcg/mL (SI: Greater Than rone levels include cimetidine.
25.6 micromol/L) Drugs that may decrease amioda-
Signs and symptoms of lidocaine tox- rone levels include cholestyramine
icity include slurred speech, central and phenytoin.
nervous system depression, cardiovas- Drugs that may increase digoxin
cular depression, convulsions, muscle levels or increase risk of toxicity
twitches, and possible coma. Possible include amiodarone, amphotericin
interventions include continuous B, diclofenac, diltiazem, erythromy-
ECG monitoring, airway support, and cin, ibuprofen, indomethacin,
seizure precautions. nifedipine, nisoldipine, propafe-
none, propantheline, quinidine,
spironolactone, tetracycline,
Procainamide: Greater Than
tiapamil, troleandomycin, and
10 mcg/mL (SI: Greater Than
verapamil.
42.5 micromol/L); N-Acetyl
Drugs that may decrease digoxin
Procainamide: Greater Than
levels include albuterol, aluminum
40 mcg/mL (SI: Greater Than
hydroxide (antacids), carbamaze-
170 micromol/L)
pine, cholestyramine, colestipol,
The active metabolite of procain-
digoxin immune Fab, hydralazine,
amide is N-acetyl procainamide
hydroxychloroquine, iron, kaolin-
(NAPA). Signs and symptoms of pro-
pectin, magnesium hydroxide,
cainamide toxicity include torsade de
magnesium trisilicate, metoclo-
pointes (ventricular tachycardia), nau-
pramide, neomycin, nitroprusside,
sea, vomiting, agranulocytosis, and
paroxetine, phenytoin, rifabutin,
hepatic disturbances. Possible inter-
sulfasalazine, and ticlopidine.
ventions include airway protection,
Drugs that may increase disopyra-
emesis, gastric lavage, and administra-
mide levels or increase risk of
tion of sodium lactate.
toxicity include amiodarone, ateno-
lol, ritonavir, and troleandomycin.
Quinidine: Greater Than Drugs that may decrease
6 mcg/mL (SI: Greater Than disopyramide levels include
18.5 micromol/L) phenobarbital, phenytoin, rifabutin,
Signs and symptoms of quinidine and rifampin.
toxicity include ataxia, nausea, vom Drugs that may increase flecainide
iting, diarrhea, respiratory system levels or increase risk of toxicity
depression, hypotension, syncope, include amiodarone and
anuria, arrhythmias (heart block, cimetidine.

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116 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

Drugs that may decrease flecainide failure, low-renin hypertension, and


levels include carbamazepine, pregnancy.
charcoal, phenobarbital, and Unexpectedly low digoxin levels
A phenytoin. may be found in patients with thy-
Drugs that may increase lidocaine roid disease.
levels or increase risk of toxicity Disopyramide may cause a
include beta blockers, cimetidine, decrease in glucose levels. It may
metoprolol, nadolol, propranolol, also potentiate the anticoagulating
and ritonavir. effects of warfarin, resulting in
Drugs that may decrease lidocaine increased PT values.
levels include phenytoin. Long-term administration of pro-
Drugs that may increase procain- cainamide can cause false-positive
amide levels or increase risk of tox- antinuclear antibody results and
icity include amiodarone, cimetidine, development of a lupuslike syn-
quinidine, ranitidine, and drome in some patients.
trimethoprim. Quinidine may potentiate the effects
Drugs that may increase quinidine of neuromuscular blocking medica-
levels or increase risk of toxicity tions and warfarin anticoagulants.
include acetazolamide, amiodarone, Concomitant administration of
cimetidine, itraconazole, mibefradil, quinidine and digoxin can rapidly
nifedipine, nisoldipine, quinidine, raise digoxin to toxic levels. If both
ranitidine, thiazide diuretics, and drugs are to be given together, the
verapamil. digoxin level should be measured
Drugs that may decrease quinidine before the first dose of quinidine
levels include kaolin-pectin, keto- and again in 4 to 6 days.
conazole, phenobarbital, phenytoin,
rifabutin, and rifampin.
Concomitant administration of
amiodarone with other medica- NURSING IMPLICATIONS
tions may result in toxic levels AND PROCEDURE
of the other medications related
to the suppression of enzyme PRETEST:
activity required to metabolize Positively identify the patient using at
many other medications by least two unique identifiers before pro-
amiodarone. It may also potentiate viding care, treatment, or services.
the anticoagulating effects of Patient Teaching: Inform the patient this
warfarin, resulting in increased test can assist in monitoring for subther-
apeutic, therapeutic, or toxic drug levels.
PT values. Obtain a history of the patients com-
Digitoxin cross-reacts with digoxin; plaints, including a list of known allergens,
results are falsely elevated if digox- especially allergies or sensitivities to latex.
in is measured when the patient is Obtain a history of the patients cardio-
taking digitoxin. vascular system, symptoms, and results
Digitalis-like immunoreactive sub- of previously performed laboratory tests
stances are found in the serum of and diagnostic and surgical procedures.
some patients who are not taking These medications are metabolized
digoxin, causing false-positive and excreted by the kidneys and liver.
Obtain a list of the patients current
results. Patients whose serum con- medications, including herbs, nutri-
tains digitalis-like immunoreactive tional supplements, and nutraceuticals
substances usually have a condi- (see Appendix H online at DavisPlus).
tion related to salt and fluid reten- Note the last time and dose of medica-
tion, such as renal failure, hepatic tion taken.

Monograph_A_111-131.indd 116 17/11/14 12:04 PM


Antiarrhythmic Drugs 117

Review the procedure with the patient. Reinforce information given by the
Inform the patient that specimen patients HCP regarding further test-
collection takes approximately 5 to ing, treatment, or referral to another
10 min. Address concerns about HCP. Explain to the patient the
pain and explain that there may importance of following the medica- A
be some discomfort during the tion regimen and instructions regard-
venipuncture. ing drug interactions. Instruct the
Sensitivity to social and cultural issues, patient to immediately report any
as well as concern for modesty, is unusual sensations (e.g., dizziness,
important in providing psychological changes in vision, loss of appetite,
support before, during, and after the nausea, vomiting, diarrhea, weak-
procedure. ness, or irregular heartbeat) to his or
Note that there are no food, fluid, or her HCP. Instruct the patient not to
medication restrictions unless by take medicine within 1 hr of food
medical direction. high in fiber (as the fiber may
decrease absorption by binding
INTRATEST: some of the medication, reducing
Potential Complications: N/A its bioavailability). Answer any ques-
tions or address any concerns voiced
Avoid the use of equipment containing
by the patient or family.
latex if the patient has a history of aller-
Instruct the patient to be prepared to
gic reaction to latex.
provide the pharmacist with a list of
Instruct the patient to cooperate fully
other medications he or she is already
and to follow directions. Direct the
taking in the event that the requesting
patient to breathe normally and to
HCP prescribes a medication.
avoid unnecessary movement.
Depending on the results of this
Observe standard precautions, and
procedure, additional testing may be
follow the general guidelines in
performed to evaluate or monitor
Appendix A. Consider recommended
progression of the disease process
collection time in relation to the dos-
and determine the need for a change
ing schedule. Positively identify the
in therapy. Testing for aspirin respon-
patient, and label the appropriate
siveness/resistance may be a consid-
specimen container with the corre-
eration for patients, especially women,
sponding patient demographics, ini-
on low-dose aspirin therapy. Evaluate
tials of the person collecting the spec-
test results in relation to the patients
imen, date, and time of collection,
symptoms and other tests performed.
noting the last dose of medication
taken. Perform a venipuncture.
Remove the needle and apply direct RELATED MONOGRAPHS:
pressure with dry gauze to stop bleed- Related tests include ALT; albumin;
ing. Observe/assess venipuncture site ALP; apolipoproteins A, B, and E;
for bleeding or hematoma formation AST; atrial natriuretic peptide; BNP;
and secure gauze with adhesive blood gases; BUN; CRP; calcium;
bandage. calcium ionized; chest x-ray; choles-
Promptly transport the specimen to the terol (total, HDL, and LDL); CBC
laboratory for processing and analysis. platelet count; CK and isoenzymes;
creatinine; ECG; glucose; glycated
POST-TEST: hemoglobin; homocysteine; ketones;
Inform the patient that a report of the LDH and isoenzymes; magnesium;
results will be made available to the myoglobin; potassium; triglycerides;
requesting HCP, who will discuss the and troponin.
results with the patient. See the Cardiovascular System table
Nutritional Considerations: Include avoid- at the end of the book for related tests
ance of alcohol consumption. by body system.

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118 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

Antibodies, Anti-Cyclic Citrullinated Peptide


A
SYNONYM/ACRONYM: Anti-CCP antibodies, ACPA.

COMMON USE: To assist in diagnosing and monitoring rheumatoid arthritis.

SPECIMEN: Serum (1 mL) collected in a gold-, red-, or red/gray-top tube.

NORMAL FINDINGS: IgG Ab (Method: Immunoassay, enzyme-linked immunosor-


bent assay [ELISA])

Negative Less than 20 units


Weak positive 2039 units
Moderate positive 4059 units
Strong positive 60 units or greater

DESCRIPTION: Rheumatoid arthritis and radiographic changes


(RA) is a chronic, systemic auto- should remain classified as having
immune disease that damages the RA. The study of RA is complex,
joints. Inflammation caused by and it is believed that multiple
autoimmune responses can affect genes may be involved in the
other organs and body systems. manifestation of RA. Scientific
The current American Academy of research has revealed an unusual
Rheumatology criteria focuses on peptide conversion from arginine
earlier diagnosis of newly present- to citrulline that results in forma-
ing patients who have at least one tion of antibodies whose pres-
swollen joint unrelated to another ence provides the basis for this
condition. The current criteria test. Studies show that detection
includes four determinants: joint of antibodies formed against
involvement (number and size of citrullinated peptides is specific
joints involved), serological test and sensitive in detecting RA in
results (rheumatoid factor [RF] both early and established dis-
and/or ACPA), indications of acute ease. Anti-CCP assays have 96%
inflammation (CRP and/or ESR), specificity and 78% sensitivity for
and duration of symptoms. A RA, compared to the traditional
score of 6 or greater defines the IgM RF marker with a specificity
presence of RA. Patients with of 60% to 80% and sensitivity of
long-standing RA, whose condi- 75% to 80% for RA. Anti-CCP anti-
tion is inactive, or whose prior bodies are being used as a marker
history would have satisfied the for erosive disease in RA, and the
previous classification criteria by antibodies have been detected in
having four of seven findings healthy patients years before the
morning stiffness, arthritis of onset of RA symptoms and diag-
three or more joint areas, arthritis nosed disease. Some studies have
of hand joints, symmetric arthri- shown that as many as 40% of
tis, rheumatoid nodules, abnormal patients seronegative for RF are
amounts of rheumatoid factor, anti-CCP positive. The combined

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Antibodies, Anti-Cyclic Citrullinated Peptide 119

allergens, especially allergies or


presence of RF and anti-CCP has sensitivities to latex.
a 99.5% specificity for RA. Women Obtain a history of the patients
are two to three times more like- immune and musculoskeletal systems,
ly than men to develop RA. symptoms, and results of previously A
Although RA is most likely to performed laboratory tests and diag-
affect people aged 35 to 50, it nostic and surgical procedures.
Obtain a list of the patients current
can affect all ages. medications, including herbs, nutri-
tional supplements, and nutraceuticals
This procedure is (see Appendix H online at DavisPlus).
Review the procedure with the patient.
contraindicated for: N/A
Inform the patient that specimen
collection takes approximately 5 to
INDICATIONS 10 min. Address concerns about pain
Assist in the diagnosis of RA in both and explain that there may be some
symptomatic and asymptomatic discomfort during the venipuncture.
individuals Sensitivity to social and cultural issues,
Assist in the identification of as well as concern for modesty, is
erosive disease in RA important in providing psychological
Assist in the diagnostic prediction support before, during, and after the
procedure.
of RA development in undifferenti-
Note that there are no food, fluid, or
ated arthritis medication restrictions unless by medi-
cal direction.
POTENTIAL DIAGNOSIS
INTRATEST:
Increased in Potential Complications: N/A
RA (The immune system produces
Avoid the use of equipment containing
antibodies that attack the joint tis-
latex if the patient has a history of aller-
sues. Inflammation of the synovi- gic reaction to latex.
um, membrane that lines the joint, Instruct the patient to cooperate fully
begins a process called synovitis. and to follow directions. Direct the
If untreated, the synovitis can patient to breathe normally and to
expand beyond the joint tissue to avoid unnecessary movement.
surrounding ligaments, tissues, Observe standard precautions,
nerves, and blood vessels.) and follow the general guidelines in
Appendix A. Positively identify the
Decreased in: N/A patient, and label the appropriate
specimen container with the corre-
CRITICAL FINDINGS: N/A sponding patient demographics, initials
of the person collecting the specimen,
INTERFERING FACTORS: N/A date, and time of collection. Perform a
venipuncture.
Remove the needle and apply direct
pressure with dry gauze to stop bleed-
NURSING IMPLICATIONS ing. Observe/assess venipuncture site
AND PROCEDURE for bleeding or hematoma formation and
secure gauze with adhesive bandage.
PRETEST: Promptly transport the specimen to the
Patient Teaching: Inform the patient this laboratory for processing and analysis.
test can assist in identifying the cause
of joint inflammation. POST-TEST:
Obtain a history of the patients Inform the patient that a report of the
complaints, including a list of known results will be made available to the

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120 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

requesting health-care provider (HCP), with disease-modifying antirheumatic


who will discuss the results with the drugs (DMARDs) and biologic response
patient. modifiers may take as long as 2 to
Recognize anxiety related to test results, 3 mo to demonstrate their effects.
A and be supportive of impaired activity Reinforce information given by the
related to anticipated chronic pain result- patients HCP regarding further testing,
ing from joint inflammation, impairment in treatment, or referral to another HCP.
mobility, muscular deformity, and per- Answer any questions or address any
ceived loss of independence. Discuss concerns voiced by the patient or family.
the implications of abnormal test results Depending on the results of this
on the patients lifestyle. Provide teaching procedure, additional testing may be per-
and information regarding the clinical formed to evaluate or monitor progres-
implications of the test results as appro- sion of the disease process and deter-
priate. Explain the importance of physical mine the need for a change in therapy.
activity in the treatment plan. Educate
the patient regarding access to physical RELATED MONOGRAPHS:
therapy, occupational therapy, and coun- Related tests include ANA, arthroscopy,
seling services. Provide contact informa- BMD, bone scan, CBC, CRP, ESR, MRI
tion, if desired, for the American College musculoskeletal, radiography bone, RF,
of Rheumatology (www.rheumatology. synovial fluid analysis, and uric acid.
org) or for the Arthritis Foundation (www Refer to the Immune and Musculoskeletal
.arthritis.org). Encourage the patient to systems tables at the end of the book for
take medications as ordered. Treatment related tests by body system.

Antibodies, Anti-Glomerular
Basement Membrane
SYNONYM/ACRONYM: Goodpastures antibody, anti-GBM.

COMMON USE: To assist in differentiating Goodpastures syndrome (an autoim-


mune disease) from renal dysfunction.

SPECIMEN: Serum (1 mL) collected in a gold-, red-, or red/gray-top tube. Lung or


kidney tissue also may be submitted for testing. Refer to related biopsy mono-
graphs for specimen-collection instructions.

NORMAL FINDINGS: (Method: Enzyme immunoassay) Less than 20 units/mL = negative.


This procedure is Goodpastures syndrome (related to
contraindicated for: N/A nephritis of autoimmune origin)
Idiopathic pulmonary
POTENTIAL DIAGNOSIS hemosiderosis
Increased in
Glomerulonephritis (of autoim- Decreased in: N/A
mune origin as evidenced by the
presence of anti-GBM antibodies) CRITICAL FINDINGS: N/A
Find and print out the full monograph at DavisPlus (http://davisplus.fadavis
.com, keyword Van Leeuwen).

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Antibodies, Actin (Smooth Muscle) and Mitochondrial M2 121

Antibodies, Actin (Smooth Muscle) and A


Mitochondrial M2
SYNONYM/ACRONYM: Antiactin antibody, ASMA; mitochondrial M2 antibody, M2
antibody, AMA.

COMMON USE: To assist in the differential diagnosis of chronic liver disease,


typically biliary cirrhosis.

SPECIMEN: Serum (1 mL) collected in a red-top tube.

NORMAL FINDINGS: (Method: Immunoassay, enzyme-linked immunosorbent [ELISA])

Actin smooth muscle antibody, IgG Mitochondrial M2 antibody, IgG

Negative Less than 20 units Negative Less than 20 units


Weak 2030 units Weak 20.124.9 units
positive positive
Positive Greater than 30 units Positive Greater than 25 units

This procedure is Actin antibodies (ASMA)


contraindicated for: N/A Autoimmune hepatitis
Chronic active viral hepatitis
POTENTIAL DIAGNOSIS Infectious mononucleosis
PBC
Increased in Primary sclerosing cholangitis
The exact cause of PBC is unknown.
There is a high degree of correla- Mitochondrial M2 antibodies (AMA)
tion between the presence of actin Hepatitis (alcoholic, viral)
smooth muscle antibodies (ASMA) PBC
and mitochodrial M2 antibodies Rheumatoid arthritis (occasionally)
(AMA) with PBC, and PBC there- Systemic lupus erythematosus
fore is thought to be an autoim- (occasionally)
mune disease. The antibodies have Thyroid disease (occasionally)
been identified in the sera of Decreased in: N/A
patients with other autoimmune
diseases. CRITICAL FINDINGS: N/A
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.com, keyword Van Leeuwen).

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122 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

Antibodies, Antineutrophilic Cytoplasmic


A
SYNONYM/ACRONYM: Cytoplasmic antineutrophil cytoplasmic antibody
(c-ANCA), perinuclear antineutrophil cytoplasmic antibody (p-ANCA).

COMMON USE: To assist in diagnosing and monitoring the effectiveness of thera-


peutic interventions for Wegeners syndrome.

SPECIMEN: Serum (1 mL) collected in a red-top tube.

NORMAL FINDINGS: (Method: Indirect immunofluorescence) Negative.


This procedure is myeloperoxidase, elastase, lacto-
contraindicated for: N/A ferrin, or other proteins.
c-ANCA
POTENTIAL DIAGNOSIS WG and its variants
Increased in p-ANCA
The exact mechanism by which Alveolar hemorrhage
ANCA are developed is unknown. Angiitis and polyangiitis
Autoimmune liver disease
One theory suggests colonization
Capillaritis
with bacteria capable of express-
Churg-Strauss syndrome
ing microbial superantigens. It is
Crescentic glomerulonephritis
thought that the superantigens Feltys syndrome
may stimulate a strong cellular Glomerulonephritis
autoimmune response in genetical- Inflammatory bowel disease
ly susceptible individuals. Another Kawasakis disease
theory suggests the immune system Leukocytoclastic skin vasculitis
may be stimulated by an accumula- Microscopic polyarteritis
tion of the antigenic targets of Rheumatoid arthritis
ANCA due to ineffective destruction Vasculitis
of old neutrophils or ineffective
Decreased in: N/A
removal of neutrophil cell frag-
ments containing proteinase, CRITICAL FINDINGS: N/A
Find and print out the full monograph at DavisPlus (http://davisplus.fadavis
.com, keyword Van Leeuwen).

Antibodies, Antinuclear, Anti-DNA,


Anticentromere, Antiextractable Nuclear
Antigen, Anti-Jo, and Antiscleroderma
SYNONYM/ACRONYM: Antinuclear antibodies (ANA), anti-DNA (anti-ds DNA),
antiextractable nuclear antigens (anti-ENA, ribonucleoprotein [RNP], Smith
[Sm], SS-A/Ro, SS-B/La), anti-Jo (antihistidyl transfer RNA [tRNA] synthase), and
antiscleroderma (progressive systemic sclerosis [PSS] antibody, Scl-70 antibody,
topoisomerase I antibody).

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Antibodies, Antinuclear, Anti-DNA, Anticentromere 123

COMMON USE: To diagnose multiple systemic autoimmune disorders; primarily


used for diagnosing systemic lupus erythematosus (SLE).

SPECIMEN: Serum (3 mL) collected in a red-top tube. A


NORMAL FINDINGS: (Method: Indirect fluorescent antibody for ANA and anticentro-
mere; Immunoassay multiplex flow for anti-DNA, ENA, Scl-70, and Jo-1)
ANA and anticentromere: Titer of 1:40 or less. Anti-ENA, Jo-1, and anti-Scl-70:
Negative. Reference ranges for anti-DNA, anti-ENA, anti-Scl-70, and anti-Jo-1 vary widely
due to differences in methods and the testing laboratory should be consulted directly.
Anti-DNA

Negative Less than 5 international units


Indeterminate 59 international units
Positive Greater than 9 international units

DESCRIPTION:Antinuclear antibod- found in various combinations in


ies (ANA) are autoantibodies individuals with combinations of
mainly located in the nucleus of overlapping rheumatologic symp-
affected cells. The presence of toms. The American College of
ANA indicates SLE, related colla- Rheumatologys current criteria
gen vascular diseases, and includes a list of 11 signs and/or
immune complex diseases. symptoms to assist in differentiat-
Antibodies against cellular DNA ing lupus from similar diseases.
are strongly associated with SLE. The patient should have four or
Anticentromere antibodies are a more of these to establish suspi-
subset of ANA. Their presence is cion of lupus; the symptoms do
strongly associated with CREST not have to manifest at the same
syndrome (calcinosis, Raynauds time: malar rash (rash over the
phenomenon, esophageal dysfunc- cheeks, sometimes described as a
tion, sclerodactyly, and telangiecta- butterfly rash), discoid rash (red
sia). Women are much more likely raised patches), photosensitivity
than men to be diagnosed with (exposure resulting in develop-
SLE. Jo-1 is an autoantibody found ment of or increase in skin rash),
in the sera of some ANA-positive oral ulcers, nonerosive arthritis
patients. Compared to the pres- involving two or more peripheral
ence of other autoantibodies, the joints, pleuritis or pericarditis,
presence of Jo-1 suggests a more renal disorder (as evidenced by
aggressive course and a higher excessive protein in urine or the
risk of mortality. The clinical presence of casts in the urine),
effects of this autoantibody neurological disorder (seizures or
include acute onset fever, dry and psychosis in the absence of drugs
crackled skin on the hands, known to cause these effects),
Raynauds phenomenon, and hematological disorder (hemolytic
arthritis. The extractable nuclear anemia, leukopenia, lymphopenia,
antigens (ENAs) include ribonu- thrombocytopenia where the leu-
cleoprotein (RNP), Smith (Sm), kopenia or lymphopenia occurs
SS-A/Ro, and SS-B/La antigens. on more than two occasions and
ENAs and antibodies to them are the thrombocytopenia occurs in
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124 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

This procedure is
the absence of drugs known to contraindicated for: N/A
cause it), positive ANA in the
absence of a drug known to INDICATIONS
A induce lupus, or immunological Assist in the diagnosis and evalua-
disorder (evidenced by positive tion of SLE
anti-ds DNA, positive anti-Sm, Assist in the diagnosis and
positive antiphospholipid such as evaluation of suspected immune
anticardiolipin antibody, positive disorders, such as rheumatoid
lupus anticoagulant test, or a false- arthritis, systemic sclerosis, polymy-
positive serological syphilis test, ositis, Raynauds syndrome, sclero-
known to be positive for at least derma, Sjgrens syndrome, and
6 months and confirmed to be mixed connective tissue disease
falsely positive by a negative Assist in the diagnosis and evalua-
Treponema pallidum immobiliza- tion of idiopathic inflammatory
tion or FTA-ABS). myopathies

POTENTIAL DIAGNOSIS

ANA Pattern* Associated Antibody Associated Condition


Rim and/or Double-stranded DNA SLE
homogeneous
Single- or double-
stranded DNA
Homogeneous Histones SLE
Speckled Sm (Smith) antibody SLE, mixed connective tissue
disease, Raynauds scleroderma,
Sjgrens syndrome
RNP* Mixed connective tissue disease,
various rheumatoid conditions
SS-B/La, SS-A/Ro Various rheumatoid conditions
Diffuse speckled Centromere PSS with CREST, Raynauds
with positive
mitotic figures
Nucleolar Nucleolar, RNP Scleroderma, CREST

*ANA patterns are helpful in that certain conditions are frequently associated with specific
patterns. RNP = ribonucleoprotein.

Increased in ANA is associated with progres-


Anti-Jo-1 is associated with sive systemic sclerosis
dermatomyositis, idiopathic ANA is associated with
inflammatory myopathies, and Raynauds syndrome
polymyositis ANA is associated with
ANA is associated with drug- rheumatoid arthritis
induced lupus erythematosus ANA is associated with Sjgrens
ANA is associated with lupoid syndrome
hepatitis ANA and anti-DNA are associated
ANA is associated with mixed with SLE
connective tissue disease Anti-RNP is associated with
ANA is associated with polymyositis mixed connective tissue disease

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Antibodies, Antinuclear, Anti-DNA, Anticentromere 125

Anti-Scl 70 is associated with Decreased in: N/A


progressive systemic sclerosis
and scleroderma CRITICAL FINDINGS: N/A
Anti-SS-A and anti-SS-B are helpful A
in antinuclear antibody (ANA) INTERFERING FACTORS
negative cases of SLE Drugs that may cause positive ANA
Anti-SS-A/ANApositive, anti-SS- results include acebutolol (diabetics),
Bnegative patients are likely to anticonvulsants (increases with con-
have nephritis comitant administration of multiple
Anti-SS-A/anti-SS-Bpositive sera are antiepileptic drugs), carbamazepine,
found in patients with neonatal chlorpromazine, ethosuximide,
lupus hydralazine, isoniazid, methyldopa,
Anti-SS-Apositive patients may oxyphenisatin, penicillins, phenytoin,
also have antibodies associated primidone, procainamide, quinidine,
with antiphospholipid syndrome and trimethadione.
Anti-SS-A/La is associated with A patient can have lupus and test
primary Sjgrens syndrome ANA-negative.
Anti-SS-A/Ro is a predictor of con- Inability of the patient to cooperate
genital heart block in neonates or remain still during the proce-
born to mothers with SLE dure because of age, significant
Anti-SS-A/Ropositive patients have pain, or mental status may interfere
photosensitivity with the test results.

NURSING IMPLICATIONS AND PROCEDURE


Potential Nursing Problems:

Problem Signs and Symptoms Interventions


Noncompliance, Triggering an acute episode Ensure the patient
risk (Related to of lupus due to excessive understands the
failure to sun exposure during peak diagnosis and disease
comply with periods process; discuss the
recommended risks of noncompliance
therapeutic on overall health
interventions;
failure to accept
diagnosis)
Skin (Related to Butterfly rash across bridge Avoid sun exposure during
rash and of nose; lesions on high-UV times; use a
lesions exposed areas of the skin; sunscreen with a UV
associated with nose and mouth ulcers protection greater than
the disease SPF 15 with sun
process) exposure; reapply
sunscreen frequently as
needed; applies
therapeutic creams or
ointments to skin as
prescribed by the
physician
(table continues on page 126)
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126 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

Problem Signs and Symptoms Interventions


Protection Fever; tenderness, redness, Vigilant hand hygiene to
A (Related to open warmth, drainage, and protect from infection;
sores; swelling of open sores monitor temperature and
decreased report any fever; monitor
immune open sores for signs of
response; infection; monitor white
steroid use) blood count; reverse
isolation if immune
system is compromised;
adequate nutrition to
promote healing
Body image Chronic erythematous coin- Emphasize strengths;
(Related to shaped raised patches determine the patients
physical (plaque) with scarring expectations regarding
changes from older lesions; fixed appearance; identify
associated with erythema, flat or raised the influence of the
the disease rash over the bridge of the patients culture,
process) nose and the cheekbones; religion, race, and
expressions of feelings or gender on body image
concerns over visual perceptions; monitor
physical changes; fear of verbalization of
rejection by others due to self-criticism
appearance

PRETEST: Sensitivity to social and cultural issues,


Positively identify the patient using at as well as concern for modesty, is
least two unique identifiers before pro- important in providing psychological
viding care, treatment, or services. support before, during, and after the
Patient Teaching: Inform the patient this procedure.
test can assist in evaluating immune Note that there are no food, fluid, or
system function. medication restrictions unless by medi-
Obtain a history of the patients com- cal direction.
plaints, including a list of known aller- INTRATEST:
gens, especially allergies or sensitivities
to latex. Potential Complications: N/A
Obtain a history of the patients Avoid the use of equipment containing
immune and musculoskeletal systems, latex if the patient has a history of
symptoms, and results of previously allergic reaction to latex.
performed laboratory tests and diag- Instruct the patient to cooperate fully
nostic and surgical procedures. and to follow directions. Direct the
Obtain a list of the patients current patient to breathe normally and to
medications, including herbs, nutri- avoid unnecessary movement.
tional supplements, and nutraceuticals Observe standard precautions, and fol-
(see Appendix H online at DavisPlus). low the general guidelines in Appendix A.
Review the procedure with the patient. Positively identify the patient, and label
Inform the patient that specimen the appropriate specimen container
collection takes approximately 5 to with the corresponding patient demo-
10 min. Address concerns about pain graphics, initials of the person collect-
and explain that there may be some ing the specimen, date, and time of
discomfort during the venipuncture. collection. Perform a venipuncture.

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Antibodies, Antinuclear, Anti-DNA, Anticentromere 127

Remove the needle and apply direct child; pregnancies should be carefully
pressure with dry gauze to stop b
leeding. planned.
Observe/assess venipuncture site for Patients with lupus are at increased risk
bleeding or hematoma formation and for infection and should discuss the
secure gauze with adhesive b andage. need for vaccinations with their HCP. A
Promptly transport the specimen to the Recommendations may include receiv-
laboratory for processing and analysis. ing vaccines during periods of remission.
Depending on the results of this
POST-TEST: procedure, additional testing may be
performed to evaluate or monitor
Inform the patient that a report of the progression of the disease process
results will be made available to the and determine the need for a change
requesting health-care provider (HCP), in therapy. Evaluate test results in
who will discuss the results with the relation to the patients symptoms and
patient. other tests performed.
Recognize anxiety related to test
results, and be supportive of perceived Patient Education:
loss of independence and fear of short-
Educate the patient regarding access
ened life expectancy. Collagen and
to counseling services.
connective tissue diseases are chronic
Educate the patient, as appropriate,
and, as such, they must be addressed
regarding the importance of preventing
on a continuous basis. Discuss the
infection, which is a significant cause of
implications of abnormal test results on
death in immunosuppressed individuals.
the patients lifestyle. Stress the impor-
Reinforce information given by the
tance of compliance to the treatment
patients HCP regarding further testing,
regimen. Instruct the patient with SLE
treatment, or referral to another HCP.
to contact the HCP immediately if new
Answer any questions or address any
symptoms present, including vague or
concerns voiced by the patient or family.
common symptoms such as fever.
Provide teaching and information
Educate the patient regarding lifestyle
regarding the clinical implications of the
changes that must be implemented to
test results, as appropriate.
protect them from increased risk of
Provide contact information, if desired,
infection and development of cardio-
for the American College of
vascular disease. Patients with lupus
Rheumatology (www.rheumatology.
should be advised to avoid direct expo-
org), the Lupus Foundation of America
sure to sunlight or other sources of UV
(www.lupus.org), or the Arthritis
light, like tanning beds (related to
Foundation (www.arthritis.org).
hypersensitivity of skin cells in people
Provide education on caring for open
with lupus to UV light. The exact
sores to prevent infection.
mechanism for this is not clearly
Discuss the importance of adequate
understood, but it is believed that in
nutrients in supporting the immune
people with lupus, damaged or dead
system and preventing infection.
skin cells are not sloughed as effi-
ciently as occurs in normal individu- Expected Patient Outcomes:
als. It is also believed that cell con-
Knowledge
tents released from damaged or dead
Describes the relationship between sun
skin cells may instigate an immune
exposure and triggering an acute lupus
response leading to development of a
episode
skin rash. Sun exposure is known to
Explains that wearing loose, long-leg
damage skin; therefore, avoiding
and long-sleeve clothing can enhance
direct exposure reduces the amount
sun protection
of damage incurred.).
Patients wishing to become pregnant Skills
should discuss the possibility with their Routinely demonstrates good hand
HCP. The stress of pregnancy and hygiene skills
medication regimen may present Demonstrates proficiency in the correct
significant risks to both mother and application of sunscreen
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128 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

Attitude bone scan, chest x-ray, complement


Identifies personal strengths to C3 and C4, complement total, CRP,
enhance self-esteem creatinine, ESR, EMG, MRI musculo-
Discusses change in appearance in a skeletal, procainamide, radiography
A positive manner bone, RF, synovial fluid analysis,
and UA.
RELATED MONOGRAPHS: See the Immune and Musculoskeletal
Related tests include antibodies anticy- systems tables at the end of the
clic citrullinated peptide, arthroscopy, book for related tests by body
biopsy kidney, biopsy skin, BMD, system.

Antibodies, Antisperm
SYNONYM/ACRONYM: Infertility screen.

COMMON USE: To evaluate testicular fertility and identify causes of infertility


such as congenital defects, cancer, and torsion.

SPECIMEN: Serum (1 mL) collected in a red-top tube.

NORMAL FINDINGS: (Method: Immunoassay)

Sperm Bound by A major cause of infertility in men is


Result Immunobead (%) blocked efferent testicular ducts.
Negative 015 Reabsorption of sperm from the
Weak positive 1630 blocked ducts may also result in
Moderate 3150 development of sperm antibodies.
positive Another more specific and sophis-
Strong 51100 ticated method than measurement
positive of circulating antibodies is the
immunobead sperm antibody test
used to identify antibodies directly
attached to the sperm. Semen and
DESCRIPTION: Normally sperm devel- cervical mucus can also be tested
op in the seminiferous tubules of the for antisperm antibodies.
testes separated from circulating
blood by the blood-testes barrier.Any
situation that disrupts this barrier This procedure is
can expose sperm to detection by contraindicated for: N/A
immune response cells in the blood
and subsequent antibody formation INDICATIONS
against the sperm.Antisperm anti- Evaluation of infertility
bodies attach to the head, midpiece,
or tail of the sperm, impairing motili- POTENTIAL DIAGNOSIS
ty and ability to penetrate the cervi- Increased in
cal mucosa.The antibodies can also Conditions that affect the integri-
cause clumping of sperm, which ty of the blood-testes barrier can
may be noted on a semen analysis. result in antibody formation.

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Antibodies, Antisperm 129

Blocked testicular efferent duct Varicocele (related to disruption


(related to absorption of sperm in the integrity of the blood-testes
by blocked vas deferens) barrier)
Congenital absence of the vas def- Vasectomy (related to absorption A
erens (related to absorption of of sperm by blocked vas deferens)
sperm by blocked vas deferens) Vasectomy reversal (related to inter-
Cryptorchidism (related to dis- action between sperm and autoanti-
ruption in the integrity of the bodies developed after vasectomy)
blood-testes barrier)
Decreased in: N/A
Infection (orchitis, prostatitis)
(related to disruption in the inte
CRITICAL FINDINGS: N/A
grity of the blood-testes barrier)
Inguinal hernia repair prior to puberty
INTERFERING FACTORS
(related to disruption in the integri-
The patient should not ejaculate for
ty of the blood-testes barrier)
3 to 4 days before specimen collec-
Testicular biopsy (related to
tion if semen will be evaluated;
disruption in the integrity of the
results may be affected if specimens
blood-testes barrier)
are collected within 48 hr of ejacu-
Testicular cancer (related to dis-
lating or after no ejaculation for
ruption in the integrity of the
longer than 5 days.
blood-testes barrier)
Sperm antibodies have been detect-
Testicular torsion (related to dis-
ed in pregnant women and in
ruption in the integrity of the
women with primary infertility.
blood-testes barrier)

NURSING IMPLICATIONS AND PROCEDURE


Potential Nursing Problems:

Problem Signs and Symptoms Interventions


Sexuality Decreased sexual Discuss the possibility of sperm
(Related to satisfaction; banking for future fertility needs;
altered sexual diminished sexual suggest counseling for patient
activity; function; ongoing and family and provide contact
diminished infertility information; facilitate a discussion
intimacy; of realistic changes to sexual
testicular intimacy associated with testicular
disease) disease; provide a relaxed
atmosphere to discuss sexuality
concerns; provide contact
information for a support group
Self-esteem Verbalizes feelings Monitor for negative self-
(Related to that express being a statements; assess for
altered view of failure as a man; withdrawal; monitor for real or
self secondary dissatisfaction with perceived rejection of others;
to altered present state of encourage verbalization of self-
ability to intimacy with worth; encourage a discussion of
participate in significant other perceived changes in family role;

(table continues on page 130)

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130 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

Problem Signs and Symptoms Interventions


sexual monitor for anxiety; recommend
A intimacy; personal and family counseling;
infertility; facilitate support group
altered body participation
image)
Fear (Related Expression of fear; Discuss the concepts of watchful
to prognosis preoccupation with waiting, surgical intervention,
secondary to fear; increased radiation therapy,
diagnosis tension; increased chemotherapy, in relation to
(cancer); blood pressure; diagnosis; access social
infertility; increased heart rate; services; provide specific and
permanently vomiting; diarrhea; culturally appropriate education;
altered sexual nausea; fatigue; assist the patient and family to
function; risk weakness; insomnia; recognize effective coping
of death; loss shortness of breath; strategies; assist the patient to
of control; increased respiratory acknowledge fear; provide a safe
ineffective rate; withdrawal; environment to decrease fear;
coping; panic attacks explore cultural influences that
unfamiliar may enhance fear; utilize
therapeutic therapeutic touch as appropriate
regime; to decrease fear; collaborate with
unknown) social services to address
specific medical problems
associated with fear
Pain (Related to Sudden testicular pain; Assess pain characteristics,
spermatic swollen tender testicle; testicular, low abdomen;
cord twisting; nausea; bloody semen; identify pain modalities that
disease visually one testicle is have relieved pain in the past;
process higher than the other; administer prescribed pain
(cancer); testicular lumps; achy medication; monitor and trend
infection) discomfort in the lower vital signs; recommend use of
abdomen; self-report of nonpharmacologic pain
pain; crying; moaning; management modalities,
sleeplessness; imagery, distraction, music,
restlessness; emotional relaxation; provide education
symptoms of distress; on postoperative pain
agitation; facial management
grimace; irritability;
diaphoresis; altered
blood pressure and
heart rate; nausea;
vomiting

PRETEST: infertility and provide guidance through


Positively identify the patient using at assistive reproductive techniques.
least two unique identifiers before pro- Obtain a history of the patients com-
viding care, treatment, or services. plaints, including a list of known aller-
Patient Teaching: Inform the patient this gens, especially allergies or sensitivities
test can assist in the evaluation of to latex.

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Antibodies, Antisperm 131

Obtain a history of the patients repro- POST-TEST:


ductive system, symptoms, and results Inform the patient that a report of the
of previously performed laboratory tests results will be made available to the
and diagnostic and surgical procedures. requesting health-care provider (HCP), who
Obtain a list of the patients current A
will discuss the results with the patient.
medications, including herbs, nutri- Recognize anxiety related to test
tional supplements, and nutraceuticals results. Discuss the implications of
(see Appendix H online at DavisPlus). abnormal test results on the patients
Review the procedure with the patient. lifestyle. Educate the patient regarding
Inform the patient that blood specimen access to counseling services.
collection takes approximately 5 to Provide a supportive, nonjudgmental
10 min and that additional specimens environment when assisting a patient
may be required. Address concerns through the process of fertility testing.
about pain and explain that there may be Depending on the results of this proce-
some discomfort during the venipuncture. dure, additional testing may be performed
Sensitivity to social and cultural issues,as to evaluate or monitor progression of the
well as concern for modesty, is impor- disease process and determine the need
tant in providing psychological support for a change in therapy. Evaluate test
before, during, and after the procedure. results in relation to the patients symp-
Note that there are no food, fluid, or med- toms and other tests performed.
ication restrictions unless by medical
direction. Patient Education:
Reinforce information given by the
INTRATEST: N/A patients HCP regarding further testing,
Potential Complications: N/A treatment, or referral to another HCP.
Answer any questions or address any
Avoid the use of equipment containing concerns voiced by the patient or family.
latex if the patient has a history of aller- Educate the patient regarding access
gic reaction to latex. to counseling services, as appropriate.
Instruct the patient to cooperate fully
and to follow directions. Direct the Expected Patient Outcomes:
patient to breathe normally and to Knowledge
avoid unnecessary movement. States understanding of therapeutic
Observe standard precautions, and fol- options as described by HCP
low the general guidelines in Appendix States understanding that infertility
A. Positively identify the patient, and may be permanent
label the appropriate specimen con-
tainer with the corresponding patient Skill
demographics, initials of the person Actively participates in a support group
collecting the specimen, date, and time to address fertility concerns
of collection. Perform a v enipuncture. Describes postoperative symptoms of
Remove the needle and apply direct infection that should be reported to the
pressure with dry gauze to stop HCP
bleeding. Observe/assess venipuncture Attitude
site for bleeding or hematoma Complies with recommendation to
formation and secure gauze with attend support group
adhesive bandage. Complies with the recommendation to
Timing of specimen collection is an attend personal and family counseling in
important instruction to follow in order relation to changes in intimacy and fertility.
to obtain accurate results if semen will
be evaluated. The testing facility should RELATED MONOGRAPHS:
be contacted for specific instructions Related tests include HCG, LH, pro-
that the patient will need to follow for gesterone, semen analysis, testoster-
specimen collection and direct, timely one, and US scrotal.
submission to the testing facility. See the Reproductive System tables
Promptly transport the specimen to the at the end of the book for related tests
laboratory for processing and analysis. by body system.
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132 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

Antibodies, Antistreptolysin O
A
SYNONYM/ACRONYM: Streptozyme, ASO.

COMMON USE: To assist in the diagnosis of streptococcal infection.

SPECIMEN: Serum (1 mL) collected in a red-top tube.

NORMAL FINDINGS: (Method: Immunoturbidimetric) Adult/older adult: Less than


200 international units/mL; 17 yr and younger: Less than 150 international units/mL.
This procedure is Endocarditis
contraindicated for: N/A Glomerulonephritis
Rheumatic fever
POTENTIAL DIAGNOSIS Scarlet fever
Increased in Decreased in: N/A
Presence of antibodies, especially a
rise in titer, is indicative of exposure. CRITICAL FINDINGS: N/A
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keyword Van Leeuwen).

Antibodies, Antithyroglobulin,
and Antithyroid Peroxidase
SYNONYM/ACRONYM: Thyroid antibodies, antithyroid peroxidase antibodies
(thyroid peroxidase [TPO] antibodies were previously called thyroid anti

microsomal antibodies).

COMMON USE: To assist in diagnosing hypothyroid and hyperthyroid disease.

SPECIMEN: Serum (1 mL) collected in a red-top tube.

NORMAL FINDINGS: (Method: Immunoassay)

Antibody Conventional Units


Antithyroglobulin antibody Less than 20 international units/mL
Antiperoxidase antibody
Newborn3 days 09 international units/mL
430 days 026 international units/mL
112 mo 013 international units/mL
13 mo19 yr 020 international units/mL
20 yrolder adult 034 international units/mL

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Antibodies, Cardiolipin, Immunoglobulin A, G and M 133

This procedure is Autoimmune disorders


contraindicated for: N/A Graves disease
Goiter
POTENTIAL DIAGNOSIS Hashimotos thyroiditis A
Idiopathic myxedema
Increased in
Pernicious anemia
The presence of these antibodies
Thyroid carcinoma
differentiates the autoimmune ori-
gin of these disorders from non- Decreased in: N/A
autoimmune causes, which may
influence treatment decisions. CRITICAL FINDINGS: N/A
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keyword Van Leeuwen).

Antibodies, Cardiolipin, Immunoglobulin A,


Immunoglobulin G, and Immunoglobulin M
SYNONYM/ACRONYM: Antiphospholipid antibody, lupus anticoagulant, LA, ACA.

COMMON USE: To detect the presence of antiphospholipid antibodies, which


can lead to the development of blood vessel problems and complications
including stroke, heart attack, and miscarriage.

SPECIMEN: Serum (1 mL) collected in a red-top tube.

NORMAL FINDINGS: (Method: Immunoassay, enzyme-linked immunosorbent assay


[ELIS])

IgA (APL = 1 unit IgG (GPL = 1 unit IgM (MPL = 1 unit


IgA phospholipid) IgG phospholipid) IgM phospholipid)
Negative: 011 APL Negative: 014 GPL Negative: 012 MPL
Indeterminate: Indeterminate: Indeterminate:
1219 APL 1519 GPL 1319 MPL
Low-medium positive: Low-medium positive: Low-medium positive:
2080 APL 2080 GPL 2080 MPL
Positive: Greater Positive: Greater Greater than 80 MPL
than 80 APL than 80 GPL

DESCRIPTION:Anticardiolipin (ACA) is fere with normal blood vessel func-


one of several identified antiphos- tion.The two primary types of prob-
pholipid antibodies.ACAs are of IgG, lems they cause are narrowing and
IgM, and IgA subtypes, which react irregularity of the blood vessels and
with proteins in the blood that are blood clots in the blood vessels.
bound to phospholipid and inter- ACAs are found in individuals with

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134 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

lupus erythematosus, lupus-related ACA IgG, or IgM, detectable at


conditions, infectious diseases, drug greater than 40 units on two or
reactions, and sometimes fetal loss. more occasions at least 12 wk
A ACAs are often found in association apart
with lupus anticoagulant. Increased Lupus anticoagulant (LA) detect-
antiphospholipid antibody levels able on two or more occasions
have been found in pregnant at least 12 wk apart
women with lupus who have had Anti-2glycoprotein 1 antibody,
miscarriages. 2 Glycoprotein 1, or IgG, or IgM detectable on two or
apolipoprotein H, is an important more occasions at least 12 wk
facilitator in the binding of apart
antiphospholipid antibodies like
ACA.A normal level of 2 glyco
This procedure is
protein 1 is 19 units or less when
contraindicated for: N/A
measured by ELISA assays.
2Glycoprotein 1 measurements are
INDICATIONS
considered to be more specific than
Assist in the diagnosis of antiphos-
ACA because they do not demon-
pholipid antibody syndrome
strate nonspecific reactivity as do
ACA in sera of patients with syphilis
POTENTIAL DIAGNOSIS
or other infectious diseases.The
combination of noninflammatory Increased in
thrombosis of blood vessels, low While ACAs are observed in specific
platelet count, and history of mis- diseases, the exact mechanism of
carriage is termed antiphospholipid these antibodies in disease is unclear.
antibody syndrome and is docu- In fact, the production of ACA can be
mented as present if at least one induced by bacterial, treponemal,
of the clinical and one of the and viral infections. Development of
laboratory criteria are met. ACA under this circumstance is tran-
sient and not associated with an
Clinical criteria increased risk of antiphospholipid
antibody syndrome. Patients who ini-
Vascular thrombosis confirmed by
tially demonstrate positive ACA levels
histopathology or imaging studies
should be retested after 6 to 8 wk to
Pregnancy morbidity defined as
rule out transient antibodies that are
either one or more unexplained
usually of no clinical significance.
deaths of a morphologically nor-
mal fetus at or beyond the 10th Antiphospholipid antibody syndrome
week of gestation Chorea
One or more premature births Drug reactions
of a morphologically normal Epilepsy
neonate before the 34th week Infectious diseases
of gestation due to eclampsia or Mitral valve endocarditis
severe pre-eclampsia Patients with lupuslike symptoms
Three or more unexplained (often antinuclear antibodynegative)
consecutive spontaneous Placental infarction
abortions before the 10th week Recurrent fetal loss (strong associa-
of gestation tion with two or more occurrences)
Laboratory criteria (all measured Recurrent venous and arterial
by a standardized ELISA, accord- thromboses
ing to recommended procedures) SLE

Monograph_A_132-152.indd 134 17/11/14 12:02 PM


Antibodies, Cardiolipin, Immunoglobulin A, G and M 135

Decreased in: N/A procainamide, phenytoin, and


quinidine.
CRITICAL FINDINGS: N/A Cardiolipin antibody is partially
cross-reactive with syphilis A
INTERFERING FACTORS reagin antibody and lupus
Drugs that may increase anticoagulant. False-positive
anticardiolipin antibody levels rapid plasma reagin results
include chlorpromazine, penicillin, may occur.

NURSING IMPLICATIONS AND PROCEDURE


Potential Nursing Problems:

Problem Signs and Symptoms Interventions


Fear (Related Verbalization of fear; Provide specific and culturally
to possible restlessness; increased appropriate education; assist
loss of tension; continuous the patient and family to
potential questioning; increased recognize effective coping
child; blood pressure, heart strategies; assist the patient to
disability; rate, respiratory rate acknowledge fear; provide a
death) safe environment to decrease
fear; explore cultural influences
that may enhance fear; utilize
therapeutic touch as
appropriate to decrease fear;
collaborate with social services
to address specific medical
problems associated with fear
Grief (Related Apparent psychological Assess decision-making ability;
to placental and emotional distress; encourage expression of
infarction withdrawal; grief; provide contact
associated detachment; loss of information for grief support
with placental appetite; refusal to group; assist to identify
cell death participate in activities current support group;
resulting in of daily living; anger; provide social services
loss of blame referral as appropriate; allow
potential the patient to recall the loss
child) and express feelings
Spirituality Forgiveness; acceptance; Encourage the verbalization
(Related to anger at spiritual of feelings in a safe
significant leaders; expressed nonjudgmental environment;
loss; fear of feelings of hopeless, assess the desire for contact
death; powerlessness; from associated spiritual
debilitation abandonment; refusals leader; foster a supportive
disease or inability to participate relationship with the patient
process) in spiritual activities and family; encourage a
(prayer); expresses display of objects (spiritual,
feelings over lack of religious) that provide
meaning with life or emotional relief; asses for
serenity expressions of hope

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136 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

Problem Signs and Symptoms Interventions


Family process Inability to perform in Family counseling; facilitating
A (Related to supportive family role; opportunities for the patient and
altered role alteration in family family to express their feelings;
performance finances; change in assess the patient and family
secondary communication perception of the problems;
to disease patterns; change in the evaluate patient and family
progression) assignment of family weaknesses, strengths, and
tasks and the coping strategies; help the
performance of those family and patient break down
tasks; alterations in concerns into manageable
intimacy parts

PRETEST: a history of allergic reaction


Positively identify the patient using to latex.
at least two unique identifiers before Instruct the patient to cooperate fully
providing care, treatment, or services. and to follow directions. Direct the
Patient Teaching: Inform the patient this patient to breathe normally and to
test can assist in evaluating the avoid unnecessary movement.
amount of potentially harmful Observe standard precautions, and fol-
circulating antibodies. low the general guidelines in Appendix A.
Obtain a history of the patients Positively identify the patient, and label
complaints, including a list of known the appropriate specimen container with
allergens, especially allergies or the corresponding patient demograph-
sensitivities to latex. ics, initials of the person collecting the
Obtain a history of the patients hema- specimen, date, and time of collection.
topoietic, immune, and reproductive Perform a venipuncture.
systems; symptoms; and results of Remove the needle and apply direct
previously performed laboratory tests pressure with dry gauze to stop
and diagnostic and surgical procedures. bleeding. Observe/assess venipunc-
Obtain a list of the patients current ture site for bleeding or hematoma
medications, including herbs, nutri- formation and secure gauze with
tional supplements, and nutraceuticals adhesive bandage.
(see Appendix H online at DavisPlus). Promptly transport the specimen to the
Review the procedure with the patient. laboratory for processing and analysis.
Inform the patient that specimen
POST-TEST:
collection takes approximately 5 to
10 min. Address concerns about pain Inform the patient that a report of the
and explain that there may be some results will be made available to the
discomfort during the venipuncture. requesting health-care provider (HCP),
Sensitivity to social and cultural issues,as who will discuss the results with the
well as concern for modesty, is impor- patient.
tant in providing psychological support Recognize anxiety related to test results,
before, during, and after the procedure. and be supportive of fear of shortened
Note that there are no food, fluid, or life expectancy. Discuss the implications
medication restrictions unless by of abnormal test results on the patients
medical direction. lifestyle. Provide teaching and informa-
tion regarding the clinical implications of
INTRATEST: the test results, as appropriate. Educate
the patient regarding access to counsel-
Potential Complications: N/A ing services. Provide contact informa-
Avoid the use of equipment tion, if desired, for the Lupus Foundation
containing latex if the patient has of America (www.lupus.org).

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Antibodies, Gliadin (Immunoglobulin G and Immunoglobulin A) 137

Depending on the results of this Skills


procedure, additional testing may Attends recommended grief counseling
be performed to evaluate or monitor for emotional and psychological
progression of the disease process support related to fetal loss.
and determine the need for a change Actively participates in the provision of A
in therapy. Evaluate test results in self-care associated with the activities
relation to the patients symptoms of daily living.
and other tests performed. Attitude
Seeks assistance from spiritual leader
Patient Education:
to relieve emotional distress associated
Reinforce information given by the with loss of potential child, or loss of
patients HCP regarding further testing, function secondary to disease process.
treatment, or referral to another HCP. Agrees to listen to the designated spiritual
Answer any questions or address any leader to assist in decreasing grief, loss.
concerns voiced by the p atient or family.
RELATED MONOGRAPHS:
Expected Patient Outcomes: Related tests include ANA, CBC, CBC
Knowledge platelet count, fibrinogen, lupus antico-
States understanding that fetal loss may agulant antibodies, protein C, protein
be associated with placental infarct. S, and syphilis serology.
States understanding of the See the Hematopoietic, Immune, and
importance in identifying a support Reproductive systems tables at the
system that can assist with coping with end of the book for related tests by
the spiritual distress of grief and loss. body system.

Antibodies, Gliadin (Immunoglobulin G


and Immunoglobulin A), Endomysial
(Immunoglobulin A), Tissue
Transglutaminase (Immunoglobulin A)
SYNONYM/ACRONYM: Endomysial antibodies (EMA), gliadin deamidated peptide
(IgG and IgA) antibodies, tTG.

COMMON USE: To assist in the diagnosis and monitoring of gluten-sensitive


enteropathies that may damage intestinal mucosa.

SPECIMEN: Serum (1 mL) collected in a red-top tube.

NORMAL FINDINGS: (Method: Enzyme linked immunosorbent assay [ELISA] for


gliadin antibody and tissue transglutaminase antibody; indirect immunofluores-
cence for endomysial antibodies)

Conventional Units
IgA and IgG Gliadin Antibody Less than 20 units
Tissue transglutaminase antibody Less than 20 units
Endomysial antibodies Negative
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138 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

DESCRIPTION: Gliadin is a water- intestinal damage as reflected by


soluble protein found in the glu- the level of detectable antibodies.
ten of wheat, rye, oats, and barley. CD shares an association with a
A The intestinal mucosa of certain number of other conditions such
individuals does not digest gluten, as type 1 diabetes, Downs syn-
allowing a toxic buildup of glia- drome, and Turners syndrome.
din and intestinal inflammation.
The inflammatory response inter-
This procedure is
feres with intestinal absorption of
contraindicated for: N/A
nutrients and damages the intesti-
nal mucosa. In severe cases, intes-
INDICATIONS
tinal mucosa can be lost.
Assist in the diagnosis of asymptom-
Immunoglobulin G (IgG) and
atic gluten-sensitive enteropathy
immunoglobulin A (IgA) gliadin
in some patients with dermatitis
antibodies are detectable in the
herpetiformis
serum of patients with gluten-sen-
Assist in the diagnosis of gluten-
sitive enteropathy. Endomysial
sensitive enteropathies
antibodies and tissue transgluta-
Assist in the diagnosis of nontropical
minase (tTG) antibody are two
sprue
other serological tests commonly
Monitor dietary compliance of
used to investigate gluten-sensi-
patients with gluten-sensitive
tive enteropathies. Gliadin IgA
enteropathies
tests are the most sensitive for
celiac disease (CD). However, it is
POTENTIAL DIAGNOSIS
also recognized that a significant
percentage of patients with CD Increased in
are also IgA deficient, meaning Evidenced by the combination of
false-negative IgA results may be detectable gliadin or endomysial
misleading in some cases. antibodies and improvement with a
Estimates of up to 98% of individ- gluten-free diet.
uals susceptible to CD carry
Asymptomatic gluten-sensitive
either the DQ2 or DQ8 HLA cell
enteropathy
surface receptors, which initiate
Celiac disease
formation of antibodies to gliadin.
Dermatitis herpetiformis (etiology
While it appears there is a strong
of this skin manifestation is
association between CD and
unknown, but there is an associa-
these gene markers, up to 40% of
tion related to gluten-sensitive
individuals without CD also carry
enteropathy)
the DQ2 or DQ8 markers.
Nontropical sprue
Molecular testing is available to
establish the absence or presence Decreased in
of these susceptibility markers. IgA deficiency (related to an
CD is an inherited condition with inability to produce IgA and
significant impact on quality of evidenced by decreased IgA levels
life for the affected individual. The and false-negative IgA gliadin
use of serological markers is use- tests)
ful in disease monitoring because Children under the age of 18 mo
research has established a rela- (related to immature immune
tionship between amount of system and low production of
gluten in the diet and degree of IgA)

Monograph_A_132-152.indd 138 17/11/14 12:02 PM


Antibodies, Gliadin (Immunoglobulin G and Immunoglobulin A) 139

CRITICAL FINDINGS: N/A INTRATEST:


Avoid the use of equipment containing
INTERFERING FACTORS latex if the patient has a history of
Conditions other than gluten-sensitive allergic reaction to latex. A
enteropathy can result in elevated Instruct the patient to cooperate fully
antibody levels without correspond- and to follow directions. Direct the
ing histological evidence.These patient to breathe normally and to
avoid unnecessary movement.
conditions include Crohns disease,
Observe standard precautions, and
postinfection malabsorption, and follow the general guidelines in
food protein intolerance. Appendix A. Positively identify the
A negative IgA gliadin result, espe- patient, and label the appropriate
cially with a positive IgG gliadin specimen container with the corre-
result in an untreated patient, does sponding patient demographics, initials
not rule out active gluten-sensitive of the person collecting the specimen,
enteropathy. date, and time of collection. Perform
a venipuncture.
Remove the needle and apply direct
NURSING IMPLICATIONS pressure with dry gauze to stop
AND PROCEDURE bleeding. Observe/assess venipunc-
ture site for bleeding or hematoma
PRETEST: formation and secure gauze with
Positively identify the patient using at adhesive bandage.
least two unique identifiers before Promptly transport the specimen to the
providing care, treatment, or services. laboratory for processing and analysis.
Patient Teaching: Inform the patient this
test can assist with evaluating the POST-TEST:
ability to digest gluten foods such as Inform the patient that a report of the
wheat, rye, and oats. results will be made available to the
Obtain a history of the patients requesting health-care provider (HCP),
complaints, including a list of known who will discuss the results with the
allergens, especially allergies or patient.
sensitivities to latex. Nutritional Considerations: Encourage the
Obtain a history of the patients patient with abnormal findings to con-
gastrointestinal and immune systems, sult with a qualified nutritionist to plan
symptoms, and results of previously a gluten-free diet. This dietary planning
performed laboratory tests and is complex because patients are often
diagnostic and surgical procedures. malnourished and have other related
Obtain a list of foods and the patients nutritional problems.
current medications, including Recognize anxiety related to test
herbs, nutritional supplements, and results, and offer support. Discuss the
nutraceuticals (see Appendix H online implications of abnormal test results on
at DavisPlus). the patients lifestyle. Provide teaching
Review the procedure with the patient. and information regarding the clinical
Inform the patient that specimen implications of the test results, as
collection takes approximately 5 to appropriate. Educate the patient
10 min. Address concerns about pain regarding access to appropriate coun-
and explain that there may be some seling services. Provide contact infor-
discomfort during the venipuncture. mation, if desired, for the Celiac
Sensitivity to social and cultural issues,as Disease Foundation (www.celiac.org)
well as concern for modesty, is important or Childrens Digestive Health and
in providing psychological support Nutrition Foundation (www.cdhnf.org).
before, during, and after the procedure. Reinforce information given by the
Note that there are no food, fluid, or patients HCP regarding further testing,
medication restrictions unless by treatment, or referral to another HCP.
medical direction. Answer any questions or address
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140 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

any concerns voiced by the patient RELATED MONOGRAPHS:


or family. Related tests include albumin, biopsy
Depending on the results of this intestine, biopsy skin, calcium, capsule
procedure, additional testing may be
A performed to evaluate or monitor
endoscopy, colonoscopy, d-xylose tol-
erance test, electrolytes, fecal analysis,
progression of the disease process fecal fat, folic acid, immunoglobulins
and determine the need for a change (IgA), iron, and lactose tolerance test.
in therapy. Evaluate test results in See the Gastrointestinal and Immune
relation to the patients symptoms systems tables at the end of the book
and other tests performed. for related tests by body system.

Anticonvulsant Drugs: Carbamazepine,


Ethosuximide, Lamotrigine, Phenobarbital,
Phenytoin, Primidone, Valproic Acid
SYNONYM/ACRONYM: Carbamazepine (Carbamazepinum, Carbategretal, Carba
trol, Carbazep, CBZ, Epitol, Tegretol, Tegretol XR); ethosuximide (Suxinutin,
Zarontin, Zartalin); lamotrigine (Lamictal) phenobarbital (Barbita, Comizial,
Fenilcal, Gardenal, Phenemal, Phenemalum, Phenobarb, Phenobarbitone,
Phenylethylmalonylurea, Solfoton, Stental Extentabs); phenytoin (Antisacer,
Dilantin, Dintoina, Diphenylan Sodium, Diphenylhydantoin, Ditan, Epanutin,
Epinat, Fenitoina, Fenytoin, Fosphenytoin); primidone (Desoxyphenobarbital,
Hexamidinum, Majsolin, Mylepsin, Mysoline, Primaclone, Prysolin); valproic
acid (Depacon, Depakene, Depakote, Depakote XR, Depamide, Dipropylacetic
Acid, Divalproex Sodium, Epilim, Ergenyl, Leptilan, 2Propylpentanoic Acid,
2Propylvaleric Acid, Valkote, Valproate Semisodium, Valproate Sodium).

COMMON USE: To monitor specific drugs for subtherapeutic, therapeutic, or


toxic levels in evaluation of treatment.

SPECIMEN: Serum (1 mL) collected in a red-top tube.

Drug* Route of Administration


Carbamazepine Oral
Ethosuximide Oral
Lamotrigine Oral
Phenobarbital Oral
Phenytoin Oral
Primidone Oral
Valproic acid Oral
*Recommended collection time = trough: immediately before next dose (at steady state) or at a
consistent sampling time.

NORMAL FINDINGS: (Method: Immunoassay for all except lamotrigine; liquid


chromatography/tandem mass spectrometry for lamotrigine)

Monograph_A_132-152.indd 140 17/11/14 12:02 PM


Therapeutic
Range Volume of Protein
Conventional Conversion Therapeutic Half-Life Distribution Binding

Monograph_A_132-152.indd 141
Drug Units to SI units Range SI Units (hr) (L/kg) (%) Excretion
Carbamazepine 412 mcg/mL SI units = Conventional 1751 1540 0.81.8 6080 Hepatic
Units 4.23 micromol/L
Ethosuximide 40100 mcg/mL SI units = Conventional 283708 2570 0.7 05 Renal
Units 7.08 micromol/L
Lamotrigine 14 mcg/mL SI units = Conventional 416 2533 0.91.3 505 Hepatic
Units 3.9 micromol/L
Phenobarbital Adult: 1540 SI units = Conventional Adult: 65172 Adult: 0.51 4050 80% Hepatic
mcg/mL Units 4.31 micromol/L 50140 and 20%
Renal
Child: 1530 SI units = Conventional Child: 65129 Child: 80%
mcg/mL Units 4.31 micromol/L 4070 Hepatic and
20% Renal
Phenytoin 1020 mcg/mL SI units = Conventional 4079 2040 0.60.7 8595 Hepatic
Units 3.96 micromol/L
Primidone Adult: 512 SI units = Conventional Adult: 2355 412 0.51 020 Hepatic
mcg/mL Units 4.58 micromol/L
Child: 710 SI units = Conventional Child: 3246
mcg/mL Units 4.58 micromol/L
Valproic acid 50125 mcg/mL SI units = Conventional 347866 815 0.10.5 8595 Hepatic
Units 6.93 micromol/L
Anticonvulsant Drugs
141

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A

17/11/14 12:02 PM
142 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

DESCRIPTION: Anticonvulsants are activation prior to metabolism, the


used to reduce the frequency and opposite occurs: PM may require a
severity of seizures for patients higher dose because the activated
A with epilepsy. Carbamazepine is drug becomes available more slow-
also used for controlling neuro- ly than intended, and UM requires
genic pain in trigeminal neuralgia less because the activated drug
and diabetic neuropathy and for becomes available sooner than
treating bipolar disease and other intended. Other genetic pheno-
neurological and psychiatric con- types used to report CYP450
ditions. Valproic acid is also used results are intermediate metaboliz-
for some psychiatric conditions er (IM) and extensive metabolizer
like bipolar disease and for pre- (EM). Genetic testing can be per-
vention of migraine headache. formed on blood samples submit-
Many factors must be consid- ted to a laboratory.The test method
ered in effective dosing and moni- commonly used is polymerase
toring of therapeutic drugs, chain reaction. Counseling and
including patient age, patient informed written consent are gen-
weight, interacting medications, erally required for genetic testing.
electrolyte balance, protein levels, CYP2C9 is a gene in the CYP450
water balance, conditions that family that metabolizes pro-drugs
affect absorption and excretion, like phenytoin as well as other
and the ingestion of substances drugs like phenobarbital; the anti-
(e.g., foods, herbals, vitamins, and coagulant warfarin; and opioid
minerals) that can either potenti- analgesics like codeine, hydrocodo-
ate or inhibit the intended target ne, dihydrocodeine, oxycodone,
concentration. Peak and trough and tramadol.Testing for the most
collection times should be docu- common genetic variants of
mented carefully in relation to the CYP2C9 is used to predict altered
time of medication administration. enzyme activity and anticipate the
The metabolism of many com- most effective therapeutic plan.
monly prescribed medications is Incidence of the PM phenotype is
driven by the cytochrome P450 estimated to be less than 0.04% of
(CYP450) family of enzymes. African Americans and less than
Genetic variants can alter enzymat- 0.1% of Caucasians and Asians.
ic activity that results in a spec-
trum of effects ranging from the
Important note
total absence of drug metabolism
These medications are metabolized
to ultrafast metabolism. Impaired
and excreted by the liver and kidneys
drug metabolism can prevent the
and are therefore contraindicated in
intended therapeutic effect or even
patients with hepatic or renal disease.
lead to serious adverse drug reac-
Caution is advised for patients with
tions. Poor metabolizers (PM) are
renal impairment. Information regard-
at increased risk for drug-induced
ing medications must be clearly and
side effects due to accumulation of
accurately communicated to avoid
drug in the blood, while ultra-rapid
misunderstanding of the dose time in
metabolizers (UM) require a higher
relation to the collection time.
than normal dosage because the
Miscommunication between the indi-
drug is metabolized over a shorter
vidual administering the medication
duration than intended. In the case
and the individual collecting the
of pro-drugs, which require
specimen is the most frequent cause

Monograph_A_132-152.indd 142 17/11/14 12:02 PM


Anticonvulsant Drugs 143

of subtherapeutic levels, toxic levels, signs and symptoms of not enough


and misleading information used in medication and too much medication.
calculation of future doses. If adminis- Note and immediately report to the
tration of the drug is delayed, notify HCP any critically increased or subther- A
the appropriate department(s) to apeutic values and related symptoms.
reschedule the blood draw and notify It is essential that a critical finding
the requesting health-care provider be communicated immediately to the
(HCP) if the delay has caused any real requesting HCP. A listing of these find-
or perceived therapeutic harm. ings varies among facilities.
Timely notification of a critical
This procedure is
finding for lab or diagnostic studies is
contraindicated for: N/A
a role expectation of the professional
INDICATIONS nurse. The notification processes will
Assist in the diagnosis of and vary among facilities. Upon receipt of
prevention of toxicity the critical finding the information
Evaluate overdose, especially in should be read back to the caller to
combination with ethanol verify accuracy. Most policies require
Monitor compliance with immediate notification of the primary
therapeutic regimen HCP, hospitalist, or on-call HCP.
Reported information includes the
POTENTIAL DIAGNOSIS patients name, unique identifiers, criti-
cal finding, name of the person giving
the report, and name of the person
Level Response receiving the report. Documentation
Normal levels Therapeutic of notification should be made in the
effect medical record with the name of the
Subtherapeutic Adjust dose HCP notified, time and date of notifica-
levels as indicated tion, and any orders received. Any
Toxic levels Adjust dose delay in a timely report of a critical
as indicated finding may require completion of a
Carbamazepine Hepatic notification form with review by Risk
impairment Management.
Ethosuximide Renal
impairment
Carbamazepine: Greater Than
Lamotrigine Hepatic
20 mcg/mL (SI: Greater Than
impairment
85 micromol/L)
Phenobarbital Hepatic or
Signs and symptoms of carbamaze-
renal
pine toxicity include respiratory
impairment
depression, seizures, leukopenia,
Phenytoin Hepatic
hyponatremia, hypotension, stupor,
impairment
and possible coma. Possible interven-
Primidone Hepatic
tions include gastric lavage (contrain-
impairment
dicated if ileus is present); airway
Valproic acid Hepatic
protection; administration of fluids
impairment
and vasopressors for hypotension;
treatment of seizures with diazepam,
CRITICAL FINDINGS phenobarbital, or phenytoin; cardiac
It is important to note the adverse monitoring; monitoring of vital signs;
effects of toxic and subtherapeutic lev- and discontinuing the medication.
els. Care must be taken to investigate Emetics are contraindicated.
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Monograph_A_132-152.indd 143 17/11/14 12:03 PM


144 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

Ethosuximide: Greater Than lethargy, CNS depression, and possible


200 mcg/mL (SI: Greater Than coma. Possible interventions include
1,416 micromol/L) airway support, electrocardiographic
A Signs and symptoms of ethosuximide monitoring, administration of activated
toxicity include nausea, vomiting, and charcoal, gastric lavage with warm
lethargy. Possible interventions include saline or tap water, administration of
administration of activated charcoal, saline or sorbitol cathartic, and discon-
administration of saline cathartic and tinuing the medication.
gastric lavage (contraindicated if ileus
is present), airway protection, hourly Primidone: Greater Than
assessment of neurologic function, and 15 mcg/mL (SI: Greater Than
discontinuing the medication. 69 micromol/L)
Signs and symptoms of primidone
Lamotrigine: Greater Than 20 mcg/ toxicity include ataxia, anemia, CNS
mL (SI: Greater Than 78 micromol/L) depression, lethargy, somnolence, ver-
Signs and symptoms of lamotrigine tigo, and visual disturbances. Possible
toxicity include severe skin rash, nau- interventions include airway protec-
sea, vomiting, ataxia, decreased levels tion, treatment of anemia with vita-
of consciousness, coma, increased sei- min B12 and folate, and discontinuing
zures, nystagmus. Possible interven- the medication.
tions include administration of acti-
vated charcoal, administration of Valproic Acid: Greater Than
saline cathartic and gastric lavage 200 mcg/mL (SI: Greater Than
(contraindicated if ileus is present), 1,386 micromol/L)
airway protection, hourly assessment Signs and symptoms of valproic acid
of neurologic function, and discon- toxicity include loss of appetite, men-
tinuing the medication tal changes, numbness, tingling, and
weakness. Possible interventions
Phenobarbital: Greater Than include administration of activated
60 mcg/mL (SI: Greater Than charcoal and naloxone and discontin-
259 micromol/L) uing the medication.
Signs and symptoms of phenobarbital
toxicity include cold, clammy skin; atax- INTERFERING FACTORS
ia; central nervous system (CNS) depres- Blood drawn in serum separator
sion; hypothermia; hypotension; cyano- tubes (gel tubes).
sis; Cheyne-Stokes respiration; tachycar- Drugs that may increase carbamaze-
dia; possible coma; and possible renal pine levels or increase risk of toxicity
impairment. Possible interventions include acetazolamide, azithromycin,
include gastric lavage, administration of bepridil, cimetidine, danazol, diltia-
activated charcoal with cathartic, air- zem, erythromycin, felodipine, fluox-
way protection, possible intubation and etine, flurithromycin, fluvoxamine,
mechanical ventilation (especially dur- gemfibrozil, isoniazid, itraconazole,
ing gastric lavage if there is no gag josamycin, ketoconazole, loratadine,
reflex), monitoring for hypotension, macrolides, niacinamide, nicardipine,
and discontinuing the medication. nifedipine, nimodipine, nisoldipine,
propoxyphene, ritonavir, terfenadine,
Phenytoin (Adults): Greater Than troleandomycin, valproic acid, vera-
40 mcg/mL (SI: Greater Than pamil, and viloxazine.
158 micromol/L) Drugs that may decrease carbam-
Signs and symptoms of phenytoin tox- azepine levels include phenobarbi-
icity include double vision, nystagmus, tal, phenytoin, and primidone.

Monograph_A_132-152.indd 144 17/11/14 12:03 PM


Anticonvulsant Drugs 145

Carbamazepine may affect other the patient is receiving primidone


body chemistries as seen by a to avoid either toxic or subthera-
decrease in calcium, sodium, peutic levels of both medications.
T3, T4 levels, and WBC count and Phenobarbital may affect other A
increase in ALT, alkaline phospha- body chemistries as seen by a
tase, ammonia, AST, and bilirubin decrease in bilirubin and calcium
levels. levels and increase in alkaline
Drugs that may increase ethosuxi- phosphatase, ammonia, and gamma
mide levels include isoniazid, glutamyl transferase levels.
ritonavir, and valproic acid. Drugs that may increase phenytoin
Drugs that may decrease ethosuxi- levels or increase the risk of phe-
mide levels include phenobarbital, nytoin toxicity include amiodarone,
phenytoin, and primidone. azapropazone, carbamazepine,
Drugs that may increase lamotri chloramphenicol, cimetidine,
gine levels include valproic acid. disulfiram, ethanol, fluconazole,
Drugs that may decrease lamotri halothane, ibuprofen, imipramine,
gine levels include acetaminophen, levodopa, metronidazole, micon-
carbamazepine, hydantoins (e.g., azole, nifedipine, phenylbutazone,
phenytoin), oral contraceptives, sulfonamides, trazodone, tricyclic
orlistat, oxcarbazepine, phenobarbi- antidepressants, and trimethoprim.
tal, primidone, protease inhibitors Small changes in formulation
(e.g., ritonavir), rifamycins (e.g., (i.e., changes in brand) also may
rifampin), and succinimides increase phenytoin levels or
(e.g., ethosuximide). increase the risk of phenytoin
Drugs that may increase phenobar- toxicity.
bital levels or increase risk of toxic- Drugs that may decrease phenyto-
ity include barbital drugs, furose- in levels include bleomycin,
mide, primidone, salicylates, and carbamazepine, cisplatin, disulfi-
valproic acid. ram, folic acid, intravenous fluids
Phenobarbital may affect the containing glucose, nitrofurantoin,
metabolism of other drugs, oxacillin, rifampin, salicylates,
increasing their effectiveness, such and vinblastine.
as -blockers, chloramphenicol, Primidone decreases the effective-
corticosteroids, doxycycline, ness of carbamazepine, ethosuxi-
griseofulvin, haloperidol, mide, felbamate, lamotrigine, oral
methylphenidate, phenothiazines, anticoagulants, oxcarbazepine,
phenylbutazone, propoxyphene, topiramate, and valproate.
quinidine, theophylline, tricyclic Primidone may affect other body
antidepressants, and valproic acid. chemistries as seen by a decrease
Phenobarbital may affect the in calcium levels and increase in
metabolism of other drugs, alkaline phosphatase levels.
decreasing their effectiveness, such Drugs that may increase valproic
as chloramphenicol, cyclosporine, acid levels or increase risk of
ethosuximide, oral anticoagulants, toxicity include dicumarol,
oral contraceptives, phenytoin, phenylbutazone, and high doses
theophylline, vitamin D, and of salicylate.
vitamin K. Drugs that may decrease valproic
Phenobarbital is an active metabo- acid levels include carbamazepine,
lite of primidone, and both drug phenobarbital, phenytoin, and
levels should be monitored while primidone.

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146 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

Direct the patient to breathe normally


NURSING IMPLICATIONS and to avoid unnecessary movement.
AND PROCEDURE Observe standard precautions, and
follow the general guidelines in
A PRETEST: Appendix A. Consider recommended
Positively identify the patient using collection time in relation to the dos-
at least two unique identifiers before ing schedule. Positively identify the
providing care, treatment, or services. patient, and label the appropriate
Patient Teaching: Inform the patient this specimen container with the corre-
test can assist with monitoring for sponding patient demographics, initials
subtherapeutic, therapeutic, or toxic of the person collecting the specimen,
drug levels. date, and time of collection, noting the
Obtain a history of the patients last dose of medication taken. Perform
complaints, including a list of known a venipuncture.
allergens, especially allergies or Remove the needle and apply direct
sensitivities to latex. pressure with dry gauze to stop
These medications are metabolized bleeding. Observe/assess venipuncture
and excreted by the kidneys and liver. site for bleeding or hematoma
Obtain a history of the patients formation and secure gauze with
genitourinary and hepatobiliary adhesive bandage.
systems, symptoms, and results of pre- Promptly transport the specimen to the
viously performed laboratory tests and laboratory for processing and analysis.
diagnostic and surgical p rocedures.
Obtain a list of the patients current
POST-TEST:
medications, including herbs,
nutritional supplements, and nutraceu- Inform the patient that a report of the
ticals (see Appendix H online at results will be made available to the
DavisPlus). Note the last time and requesting HCP, who will discuss the
dose of medication taken. results with the patient.
Review the procedure with the patient. Nutritional Considerations: Antiepileptic
Inform the patient that specimen drugs antagonize folic acid, and there
collection takes approximately 5 to is a corresponding slight increase in
10 min. Address concerns about pain the incidence of fetal malformations in
and explain that there may be some children of epileptic mothers. Women
discomfort during the venipuncture. of childbearing age who are taking
Sensitivity to social and cultural issues,as carbamazepine, phenobarbital,
well as concern for modesty, is impor- phenytoin, primadone, and/or valproic
tant in providing psychological support acid should also be prescribed
before, during, and after the procedure. supplemental folic acid to reduce the
Note that there are no food, fluid, or incidence of neural tube defects.
medication restrictions unless by Neonates born to epileptic mothers
medical direction. taking antiseizure medications during
pregnancy may experience a tempo-
INTRATEST: rary drug-induced deficiency of vita-
min Kdependent coagulation factors.
Potential Complications: This can be avoided by administration
Lack of consideration for the proper of vitamin K to the mother in the last
collection time relative to the dosing few weeks of pregnancy and to the
schedule can provide misleading infant at birth.
information that may result in errone- Reinforce information given by the
ous interpretation of levels, creating the patients HCP regarding further testing,
potential for a medication-error-related treatment, or referral to another HCP.
injury to the patient. Explain to the patient the importance
Avoid the use of equipment containing of following the medication regimen
latex if the patient has a history of and instructions regarding drug
allergic reaction to latex. interactions. Instruct the patient to

Monograph_A_132-152.indd 146 17/11/14 12:03 PM


Antideoxyribonuclease-B, Streptococcal 147

immediately report any unusual rogression of the disease process


p
sensations (e.g., ataxia, dizziness, and determine the need for a change
dyspnea, lethargy, rash, tremors, men- in therapy. Evaluate test results in
tal changes, weakness, or visual dis- relation to the patients symptoms and
turbances) to his or her HCP. Answer other tests performed. A
any questions or address any con-
cerns voiced by the patient or family. RELATED MONOGRAPHS:
Instruct the patient to be prepared to Related tests include ALT, albumin,
provide the pharmacist with a list of AST, bilirubin, BUN, creatinine,
other medications he or she is already electrolytes, GGT, and protein blood
taking in the event that the requesting total and fractions.
HCP prescribes a medication. See the Genitourinary and
Depending on the results of this Hepatobiliary systems tables at the
procedure, additional testing may end of the book for related tests by
be performed to evaluate or monitor body system.

Antideoxyribonuclease-B, Streptococcal
SYNONYM/ACRONYM: ADNase-B, AntiDNase-B titer, antistreptococcal DNase-B
titer, streptodornase.

COMMON USE: To assist in assessing the cause of recent infection, such as strep-
tococcal exposure, by identification of antibodies.

SPECIMEN: Serum (1 mL) collected in a red-top tube.

NORMAL FINDINGS: (Method: Nephelometry)

Age Normal Results


16 yr Less than 250 units
717 yr Less than 375 units
18 yr and older Less than 300 units

This procedure is Post streptococcal


contraindicated for: N/A glomerulonephritis
Rheumatic fever
POTENTIAL DIAGNOSIS Streptococcal infections
(systemic)
Increased in
Presence of antibodies, especially Decreased in: N/A
a rise in titer, is indicative of
exposure. CRITICAL FINDINGS: N/A
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com, keyword Van Leeuwen).

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Monograph_A_132-152.indd 147 17/11/14 12:03 PM


148 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

Antidepressant Drugs (Cyclic): Amitriptyline,


Nortriptyline, Protriptyline, Doxepin,
Imipramine
SYNONYM/ACRONYM: Cyclic antidepressants: amitriptyline (Elavil, Endep,
Etrafon, Limbitrol, Triavil); nortriptyline (Allegron, Aventyl HCL, Nortrilen,
Norval, Pamelor); protriptyline (Aventyl, Sinequan, Surmontil, Tofranil, Vivactil);
doxepin (Adapin, Co-Dax, Novoxapin, Sinequan, Triadapin); imipramine
(Berkomine, Dimipressin, Iprogen, Janimine, Pentofrane, Presamine, SK-Pramine,
Tofranil PM).

COMMON USE: To monitor subtherapeutic, therapeutic, or toxic drug levels in


evaluation of effective treatment modalities.

SPECIMEN: Serum (1 mL) collected in a red-top tube.

Route of
Drug Administration Recommended Collection Time
Amitriptyline Oral Trough: immediately before next dose
(at steady state)
Nortriptyline Oral Trough: immediately before next dose
(at steady state)
Protriptyline Oral Trough: immediately before next dose
(at steady state)
Doxepin Oral Trough: immediately before next dose
(at steady state)
Imipramine Oral Trough: immediately before next dose
(at steady state)

NORMAL FINDINGS: (Method: Chromatography for amitriptyline, nortriptyline,


protriptyline, and doxepin; immunoassay for imipramine)

Monograph_A_132-152.indd 148 17/11/14 12:03 PM


Therapeutic

Monograph_A_132-152.indd 149
Range Therapeutic Volume of Protein
Conventional Conversion Range Half-Life Distribution Binding
Drug Units to SI units SI Units (h) (L/kg) (%) Excretion
Amitriptyline 125250 ng/mL SI units = 450900 nmol/L 2040 1036 8595 Hepatic
Conventional
Units 3.6
Nortriptyline 50150 ng/mL SI units = 190570 nmol/L 2060 1523 9095 Hepatic
Conventional
Units 3.8
Protriptyline 70250 ng/mL SI units = 266950 nmol/L 6090 1531 9193 Hepatic
Conventional
Units 3.8
Doxepin 110250 ng/mL SI units = 394895 nmol/L 1025 1030 7585 Hepatic
Conventional
Units 3.58
Imipramine 180240 ng/mL SI units = 643857 nmol/L 618 923 6095 Hepatic
Conventional
Units 3.57
Antidepressant Drugs (Cyclic)
149

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A

17/11/14 12:03 PM
150 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

DESCRIPTION: Cyclic antidepres- henotypes used to report


p
sants are used in the treatment of CYP450 results are intermediate
major depression.They have also metabolizer (IM) and extensive
A been used effectively to treat bipo- metabolizer (EM). Genetic testing
lar disorder, panic disorder, atten- can be performed on blood sam-
tion deficit-hyperactivity disorder ples submitted to a laboratory. The
(ADHD), obsessive-compulsive test method commonly used is
disorder (OCD), enuresis, eating polymerase chain reaction.
disorders (bulimia nervosa in Counseling and informed written
particular), nicotine dependence consent are generally required for
(tobacco), and cocaine dependence. genetic testing. CYP2D6 is a gene
Numerous drug interactions occur in the CYP450 family that metabo-
with the cyclic antidepressants. lizes drugs such as tricyclic antide-
Many factors must be consid- pressants like nortriptyline, anti-
ered in effective dosing and psychotics like haloperidol, and
monitoring of therapeutic drugs, beta blockers. Testing for the most
including patient age, patient common genetic variants of
ethnicity, patient weight, interact- CYP2D6 is used to predict altered
ing medications, electrolyte bal- enzyme activity and anticipate the
ance, protein levels, water balance, most effective therapeutic plan.
conditions that affect absorption Incidence of the PM phenotype is
and excretion, and the ingestion of estimated to be 10% of Caucasians
substances (e.g., foods, herbals, vita- and Hispanics, 2% of African
mins, and minerals) that can either Americans, and 1% of Asians.
potentiate or inhibit the intended
target concentration.Trough collec-
IMPORTANT NOTE
tion times should be documented
These medications are metabolized
carefully in relation to the time of
and excreted by the liver and are
medication administration.
therefore contraindicated in patients
The metabolism of many com-
with hepatic disease. Information
monly prescribed medications is
regarding medications must be clearly
driven by the cytochrome P450
and accurately communicated to
(CYP450) family of enzymes.
avoid misunderstanding of the dose
Genetic variants can alter enzymat-
time in relation to the collection time.
ic activity that results in a spec-
Miscommunication between the indi-
trum of effects ranging from the
vidual administering the medication
total absence of drug metabolism
and the individual collecting the spec-
to ultrafast metabolism. Impaired
imen is the most frequent cause of
drug metabolism can prevent the
subtherapeutic levels, toxic levels,
intended therapeutic effect or
and misleading information used in
even lead to serious adverse drug
calculation of future doses. If adminis-
reactions. Poor metabolizers (PM)
tration of the drug is delayed, notify
are at increased risk for drug-
the appropriate department(s) to
induced side effects due to accu-
reschedule the blood draw and notify
mulation of drug in the blood,
the requesting health-care provider
while ultra-rapid metabolizers
(HCP) if the delay has caused any real
(UM) require a higher than
or perceived therapeutic harm.
normal dosage because the drug
is metabolized over a shorter dura- This procedure is
tion than intended. Other genetic contraindicated for: N/A

Monograph_A_132-152.indd 150 17/11/14 12:03 PM


Antidepressant Drugs (Cyclic) 151

INDICATIONS Documentation of notification should


Assist in the diagnosis and be made in the medical record with the
prevention of toxicity name of the HCP notified, time and date
Evaluate overdose, especially in of notification, and any orders received. A
combination with ethanol Any delay in a timely report of a critical
(Note: Doxepin abuse is unusual.) finding may require completion of a
Monitor compliance with notification form with review by Risk
therapeutic regimen Management.
Cyclic Antidepressants
POTENTIAL DIAGNOSIS
Amitriptyline: Greater Than 500 ng/
mL (SI: Greater Than 1800 nmol/L)
Level Response Nortriptyline: Greater Than 500 ng/
Normal levels Therapeutic effect mL (SI: Greater Than 1900 nmol/L)
Subtherapeutic Adjust dose as Protriptyline: Greater Than 500 ng/
levels indicated mL (SI: Greater Than 1900 nmol/L)
Toxic levels Adjust dose as Doxepin: Greater Than 500 ng/mL
indicated (SI: Greater Than 1790 nmol/L)
Amitriptyline Hepatic impairment Imipramine: Greater Than 500 ng/
Nortriptyline Hepatic impairment mL (SI: Greater Than 1785 nmol/L)
Protriptyline Hepatic impairment Signs and symptoms of cyclic antide-
Doxepin Hepatic impairment pressant toxicity include agitation,
Imipramine Hepatic impairment drowsiness, hallucinations, confusion,
seizures, arrhythmias, hyperthermia,
CRITICAL FINDINGS flushing, dilation of the pupils, and pos-
It is important to note the adverse sible coma. Possible interventions
effects of toxic and subtherapeutic lev- include administration of activated char-
els of antidepressants. Care must be coal; emesis; gastric lavage with saline;
taken to investigate signs and symptoms administration of physostigmine to
of too little and too much medication. counteract seizures, hypertension, or
Note and immediately report to the respiratory depression; administration
HCP any critically increased or subther- of bicarbonate, propranolol, lidocaine,
apeutic values and related symptoms. or phenytoin to counteract arrhythmias;
It is essential that a critical finding and electrocardiographic monitoring.
be communicated immediately to the
INTERFERING FACTORS
requesting HCP. A listing of these find-
Blood drawn in serum separator
ings varies among facilities.
tubes (gel tubes).
Timely notification of a critical find-
Cyclic antidepressants may
ing for lab or diagnostic studies is a role
potentiate the effects of oral
expectation of the professional nurse.
anticoagulants.
The notification processes will vary
among facilities. Upon receipt of the
critical finding the information should NURSING IMPLICATIONS
be read back to the caller to verify accu- AND PROCEDURE
racy. Most policies require immediate
notification of the primary HCP, hospi- PRETEST:
talist, or on-call HCP. Reported informa- Positively identify the patient using at
tion includes the patients name, unique least two unique identifiers before
identifiers, critical finding, name of the providing care, treatment, or services.
person giving the report, and name of Patient Teaching: Inform the patient
the person receiving the report. this test can assist in monitoring

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152 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

subtherapeutic, therapeutic, or toxic person collecting the specimen, date,


drug levels. and time of collection, noting the last
Obtain a history of the patients dose of medication taken. Perform
complaints, including a list of known a venipuncture.
A allergens, especially allergies or Remove the needle and apply direct
sensitivities to latex. pressure with dry gauze to stop
These medications are metabolized bleeding. Observe/assess venipuncture
and excreted by the kidneys and liver. site for bleeding or hematoma
Obtain a history of the patients genito- formation and secure gauze with
urinary and hepatobiliary systems, adhesive bandage.
symptoms, and results of previously Promptly transport the specimen to the
performed laboratory tests and laboratory for processing and a nalysis.
diagnostic and surgical procedures.
Obtain a list of the patients current medi- POST-TEST:
cations, including herbs, nutritional Inform the patient that a report of the
supplements, and nutraceuticals (see results will be made available to the
Appendix H online at DavisPlus). Note the requesting HCP, who will discuss the
last time and dose of medication taken. results with the patient.
Review the procedure with the patient. Nutritional Considerations: Include
Inform the patient that specimen avoidance of alcohol consumption.
collection takes approximately 5 to Recognize anxiety related to test results
10 min. Address concerns about pain and reinforce information given by the
and explain that there may be some patients HCP regarding further testing,
discomfort during the venipuncture. treatment, or referral to another HCP.
Sensitivity to social and cultural issues,as Explain to the patient the importance of
well as concern for modesty, is important following the medication regimen and
in providing psychological support instructions regarding drug interactions.
before, during, and after the procedure. Instruct the patient to immediately report
Note that there are no food, fluid, or any unusual sensations (e.g., severe
medication restrictions unless by headache, vomiting, sweating, visual
medical direction. disturbances) to his or her HCP. Blood
pressure should be monitored regularly.
INTRATEST:
Answer any questions or address any
Potential Complications: concerns voiced by the patient or family.
Lack of consideration for the proper Instruct the patient to be prepared to
collection time relative to the dosing provide the pharmacist with a list of
schedule can provide misleading infor- other medications he or she is already
mation that may result in erroneous taking in the event that the requesting
interpretation of levels, creating the HCP prescribes a medication.
potential for a medication-error-related Depending on the results of this
injury to the patient. procedure, additional testing may be
Avoid the use of equipment containing performed to evaluate or monitor
latex if the patient has a history of aller- progression of the disease process
gic reaction to latex. and determine the need for a change
Instruct the patient to cooperate fully in therapy. Evaluate test results in
and to follow directions. Direct the relation to the patients symptoms and
patient to breathe normally and to other tests performed.
avoid unnecessary movement.
Observe standard precautions, and RELATED MONOGRAPHS:
follow the general guidelines in Related tests include ALT, albumin,
Appendix A. Consider recommended AST, bilirubin, BUN, creatinine, CBC,
collection time in relation to the dosing electrolytes, GGT, and protein blood
schedule. Positively identify the patient, total and fractions.
and label the appropriate specimen See the Genitourinary and Hepatobiliary
container with the corresponding systems tables at the end of the book
patient demographics, initials of the for related tests by body system.

Monograph_A_132-152.indd 152 17/11/14 12:03 PM


Antidiuretic Hormone 153

Antidiuretic Hormone
A
SYNONYM/ACRONYM: Vasopressin, arginine vasopressin hormone, ADH.

COMMON USE: To evaluate disorders that affect urine concentration related to


fluctuations of ADH secretion, such as diabetes insipidus.

SPECIMEN: Plasma (1 mL) collected in a lavender-top (EDTA) tube.

NORMAL FINDINGS: (Method: Radioimmunoassay)

SI Units
Antidiuretic (Conventional Units
Age Hormone* 0.923)
Neonates Less than 1.5 pg/mL Less than 1.4 pmol/L
1 day18 yr 0.51.7 pg/mL Less than 0.51.6 pmol/L
(normally hydrated)
Adult (normally 05 pg/mL 04.6 pmol/L
hydrated)

*Conventional units.

Recommendation
This test should be ordered and interpreted with results of a serum osmolality.

SI Units (Conventional
Serum Osmolality* Antidiuretic Hormone Units 0.923)
270280 mOsm/kg Less than 1.5 pg/mL Less than 1.4 pmol/L
280285 mOsm/kg Less than 2.5 pg/mL Less than 2.3 pmol/L
285290 mOsm/kg 15 pg/mL 0.94.6 pmol/L
290295 mOsm/kg 27 pg/mL 1.86.5 pmol/L
295300 mOsm/kg 412 pg/mL 3.711.1 pmol/L

*Conventional units.
release from damaged cells in an
This procedure is
adjacent affected area)
contraindicated for: N/A
Disorders involving the central ner-
POTENTIAL DIAGNOSIS vous system, thyroid gland, and adre-
nal gland (numerous conditions
Increased in influence the release of ADH)
Acute intermittent porphyria Ectopic production (related to
(speculated to be related to the ADH production from a systemic
release of ADH from damaged neoplasm)
cells in the hypothalamus and Guillain-Barr; syndrome (relation-
effect of hypovolemia; the mecha- ship to syndrome of inappropri-
nisms are unclear) ate ADH [SIADH] is unclear)
Brain tumor (related to ADH Hypovolemia (potent instigator of
production from the tumor or ADH release)
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Monograph_A_153-190.indd 153 17/11/14 12:03 PM


154 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

Nephrogenic diabetes insipidus Nephrotic syndrome (related to


(related to lack of renal system destruction of pituitary cells that
response to ADH stimulation; evi- secrete ADH)
A denced by increased secretion of Pituitary (central) diabetes insipi-
ADH) dus (related to destruction of
Pain, stress, or exercise (all are pituitary cells that secrete ADH)
potent instigators of ADH Pituitary surgery (related to
release) destruction or removal of pitu-
Pneumonia (related to SIADH) itary cells that secrete ADH)
Pulmonary tuberculosis (related to Psychogenic polydipsia (evidenced
SIADH) by decreased osmolality, which
SIADH (numerous conditions inhibits secretion of ADH)
influence the release of ADH)
Tuberculous meningitis (related to CRITICAL FINDINGS
SIADH) Effective treatment of SIADH depends
on identifying and resolving the cause
Decreased in
of increased ADH production. Signs
Decreased production or secretion
and symptoms of SIADH are the same
of ADH in response to changes in
as those for hyponatremia, including
blood volume or pressure
irritability, tremors, muscle spasms,
Hypervolemia (related to convulsions, and neurologic changes.
increased blood volume, which The patient has enough sodium, but it
inhibits secretion of ADH) is diluted in excess retained water.
Find and print out the full monograph at DavisPlus (http://davisplus.fadavis
.com, keyword Van Leeuwen).

Antimicrobial DrugsAminoglycosides:
Amikacin, Gentamicin, Tobramycin; Tricyclic
Glycopeptide: Vancomycin
SYNONYM/ACRONYM: Amikacin (Amikin); gentamicin (Garamycin, Genoptic,
Gentacidin, Gentafair, Gentak, Gentamar, Gentrasul, G-myticin, Oco-Mycin,
Spectro-Genta); tobramycin (Nebcin, Tobrex); vancomycin (Lyphocin,
Vancocin, Vancoled).

COMMON USE: To evaluate specific drugs for subtherapeutic, therapeutic, or


toxic levels in treatment of infection.

SPECIMEN: Serum (1 mL) collected in a red-top tube.

Monograph_A_153-190.indd 154 17/11/14 12:03 PM


Antimicrobial DrugsAminoglycosides 155

Route of
Drug Administration Recommended Collection Time*
Amikacin IV, IM Trough: immediately before next dose A
Peak: 30 min after the end of a 30-min
IV infusion
Gentamicin IV, IM Trough: immediately before next dose
Peak: 30 min after the end of a 30-min
IV infusion
Tobramycin IV, IM Trough: immediately before next dose
Peak: 30 min after the end of a 30-min
IV infusion
Tricyclic IV, PO Trough: immediately before next dose
glycopeptide and Peak: 3060 min after the end of a
vancomycin 60-min IV infusion

*Usually after fifth dose if given every 8 hr or third dose if given every 12 hr. IM = intramuscular;
IV = intravenous; PO = by mouth.

NORMAL FINDINGS: (Method: Immunoassay)

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Monograph_A_153-190.indd 155 17/11/14 12:03 PM


A
Volume of
156

Therapeutic Range Conversion to Half-Life Distribution Binding


Drug Conventional Units SI units SI Units (hr) (L/kg) (%) Excretion
Amikacin
Peak 1530 mcg/mL SI units = 2651 48 0.41.3 50 1 renal

Monograph_A_153-190.indd 156
Conventional micromol/L
Units 1.71
Trough 48 mcg/mL SI units = 714 1 renal
Conventional micromol/L
Units 1.71
Gentamicin (Standard dosing)
Peak 510 mcg/mL SI units = 1021 48 0.41.3 50 1 renal
Conventional micromol/L
Units 2.09
Trough Less than 2 mcg/mL SI units = Less than 4 1 renal
Conventional micromol/L
Units 2.09
Tobramycin (Standard dosing)
Peak 48 mcg/mL SI units = 8.416.7 48 0.41.3 50 1 renal
Conventional micromol/L
Units 2.09
Trough Less than 1 mcg/mL SI units = Less than 2.1 1 renal
Conventional micromol/L
Units 2.09
Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

17/11/14 12:03 PM
Monograph_A_153-190.indd 157
Volume of
Therapeutic Range Conversion to Half-Life Distribution Binding
Drug Conventional Units SI units SI Units (hr) (L/kg) (%) Excretion
Tobramycin (Once daily dosing)
Peak 812 mcg/mL SI units = 16.725.1 48 0.41.3 50 1 renal
Conventional micromol/L
Units 2.09

Trough Less than 0.5 mcg/mL SI units = Less than 1 1 renal


Conventional micromol/L
Units 2.09
Vancomycin
Trough 515 mcg/mL SI units = 3.410.4 612 0.41 1015 1 renal
(General) Conventional micromol/L
Values vary Units 0.69
with indication
Antimicrobial DrugsAminoglycosides
157

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A

17/11/14 12:03 PM
158 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

DESCRIPTION:The aminoglycoside trough collection times should be


antibiotics amikacin, gentamicin, documented carefully in relation
and tobramycin are used to the time of medication admin-
A against many gram-negative istration. Creatinine levels should
(Acinetobacter, Citrobacter, be monitored every 2 to 3 days
Enterobacter, Escherichia coli, to detect renal impairment due
Klebsiella, Proteus, Providencia, to toxic drug levels.
Pseudomonas, Raoultella,
Salmonella, Serratia, Shigella,
and Stenotrophomonas) and some
gram-positive (Staphylococcus IMPORTANT NOTE: These medications
aureus) pathogenic microorgan- are metabolized and excreted by the
isms. Aminoglycosides are poorly kidneys and are therefore contraindi-
absorbed through the gastrointesti- cated in patients with renal disease
nal tract and are most frequently and cautiously advised in patients with
administered IV. renal impairment. Information regard-
Vancomycin is a tricyclic gly- ing medications must be clearly and
copeptide antibiotic used against accurately communicated to avoid
many gram-positive microorgan- misunderstanding of the dose time
isms, such as staphylococci, in relation to the collection time.
Streptococcus pneumoniae, Miscommunication between the indi-
group A -hemolytic streptococci, vidual administering the medication
enterococci, Corynebacterium, and the individual collecting the speci-
and Clostridium. Vancomycin has men is the most frequent cause of sub-
also been used in an oral form therapeutic levels, toxic levels, and mis-
for the treatment of pseudomem- leading information used in the calcula-
branous colitis resulting from tion of future doses. Some pharmacies
Clostridium difficile infection. use a computerized pharmacokinetics
This approach is less frequently approach to dosing that eliminates the
used because of the emergence need to be concerned about peak and
of vancomycin-resistant entero- trough collections; random specimens
cocci (VRE). are adequate. If administration of the
Many factors must be consid- drug is delayed, notify the appropriate
ered in effective dosing and mon- department(s) to reschedule the blood
itoring of therapeutic drugs, draw and notify the requesting health-
including patient age, patient care provider (HCP) if the delay has
weight, interacting medications, caused any real or perceived therapeu-
electrolyte balance, protein levels, tic harm.
water balance, conditions that This procedure is
affect absorption and excretion, contraindicated for: N/A
and ingestion of substances (e.g.,
foods, herbals, vitamins, and min- INDICATIONS
erals) that can either potentiate Assist in the diagnosis and preven-
or inhibit the intended target tion of toxicity
concentration. The most serious Monitor renal dialysis patients or
side effects of the aminoglyco- patients with rapidly changing
sides and vancomycin are neph- renal function
rotoxicity and irreversible ototox- Monitor therapeutic regimen
icity (uncommon). Peak and

Monograph_A_153-190.indd 158 17/11/14 12:03 PM


Antimicrobial DrugsAminoglycosides 159

POTENTIAL DIAGNOSIS

Level Response
A
Normal levels Therapeutic effect
Subtherapeutic levels Adjust dose as indicated
Toxic levels Adjust dose as indicated
Amikacin Renal, hearing impairment
Gentamicin Renal, hearing impairment
Tobramycin Renal, hearing impairment
Vancomycin Renal, hearing impairment

CRITICAL FINDINGS giving the report, and name of the


person receiving the report.
The adverse effects of subtherapeu- Documentation of notification should
tic levels are important. Care should be made in the medical record with
be taken to investigate signs and the name of the HCP notified, time
symptoms of too little and too much and date of notification, and any
medication. Note and immediately orders received. Any delay in a timely
report to the health-care provider report of a critical finding may require
(HCP) any critically increased or completion of a notification form
subtherapeutic values and related with review by Risk Management.
symptoms. Signs and symptoms of toxic lev-
Timely notification of a critical els of these antibiotics are similar and
finding for lab or diagnostic studies is include loss of hearing and decreased
a role expectation of the professional renal function. Suspected hearing loss
nurse. The notification processes will can be evaluated by audiometry test-
vary among facilities. Upon receipt of ing. Impaired renal function may be
the critical finding the information identified by monitoring BUN and
should be read back to the caller to creatinine levels as well as intake and
verify accuracy. Most policies require output. The most important interven-
immediate notification of the primary tion is accurate therapeutic drug
HCP, hospitalist, or on-call HCP. monitoring so the medication can be
Reported information includes the discontinued before irreversible dam-
patients name, unique identifiers, age is done.
critical finding, name of the person

Toxic Levels
Drug Name Conventional Units Toxic Levels SI Units
Amikacin Greater than 10 mcg/mL Greater than 17.1 micromol/L
Gentamicin Peak greater than Peak greater than 25.1 micromol/L,
12 mcg/mL, trough trough greater than 4.2
greater than 2 mcg/mL micromol/L
Tobramycin Peak greater than Peak greater than 25.1 micromol/L,
12 mcg/mL, trough trough greater than
greater than 2 mcg/mL 4.2 micromol/L
Vancomycin Trough greater than Trough greater than
30 mcg/mL 20.7 micromol/L

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160 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

INTERFERING FACTORS Review the procedure with the patient.


Blood drawn in serum separator Inform the patient that specimen collec
tubes (gel tubes). tion takes approximately 5 to 10 min.
Drugs that may decrease aminogly- Address concerns about pain and
A explain that there may be some dis
coside efficacy include penicillins comfort during the venipuncture.
(e.g., carbenicillin, piperacillin). Obtain a culture, if ordered, before the
Obtain a culture before and after first dose of aminoglycosides.
the first dose of aminoglycosides. Sensitivity to social and cultural issues,
The risks of ototoxicity and neph- as well as concern for modesty, is
rotoxicity are increased by the con- important in providing psychological
comitant administration of amino- support before, during, and after the
glycosides. procedure.
Note that there are no food, fluid, or
medication restrictions unless by medi
cal direction.
NURSING IMPLICATIONS
AND PROCEDURE INTRATEST:

PRETEST: Potential Complications: N/A

Positively identify the patient using Avoid the use of equipment containing
at least two unique identifiers before latex if the patient has a history of aller
providing care, treatment, or services. gic reaction to latex.
Patient Teaching: Inform the patient this Instruct the patient to cooperate fully
test can assist in monitoring for sub and to follow directions. Direct the
therapeutic, therapeutic, or toxic drug patient to breathe normally and to
levels used in treatment of infection. avoid unnecessary movement.
Obtain a history of the patients com Observe standard precautions, and fol
plaints, including a list of known aller low the general guidelines in Appendix A.
gens, especially allergies or sensitivities Consider recommended collection time
to latex. in relation to the dosing schedule.
Obtain a history of the patients immune Positively identify the patient, and label
system, symptoms, and results of pre the appropriate specimen container
viously performed laboratory tests and with the corresponding patient demo
diagnostic and surgical procedures. graphics, initials of the person collect
Nephrotoxicity is a risk associated with ing the specimen, date, and time of
administration of aminoglycosides. collection, noting the last dose of med
Obtain a history of the patients genito ication taken. Perform a venipuncture.
urinary system, symptoms, and results Remove the needle and apply direct
of previously performed laboratory pressure with dry gauze to stop
tests and diagnostic and surgical bleeding. Observe/assess venipunc
procedures. ture site for bleeding or hematoma
Ototoxicity is a risk associated with formation and secure gauze with
administration of aminoglycosides. adhesive bandage.
Obtain a history of the patients known Promptly transport the specimen to the
or suspected hearing loss, including laboratory for processing and analysis.
type and cause; ear conditions with
treatment regimens; ear surgery; and POST-TEST:
other tests and procedures to assess Inform the patient that a report of the
and diagnose auditory deficit. results will be made available to the
Obtain a list of the patients current requesting HCP, who will discuss the
medications, including herbs, nutri results with the patient.
tional supplements, and nutraceuticals Instruct the patient receiving aminoglyco
(see Appendix H online at DavisPlus). sides to immediately report any unusual
Note the last time and dose of medica symptoms (e.g., hearing loss, decreased
tion taken. urinary output) to his or her HCP.

Monograph_A_153-190.indd 160 17/11/14 12:03 PM


Antipsychotic Drugs and Antimanic Drugs: Haloperidol, Lithium 161

Nutritional Considerations: Include avoid Depending on the results of this


ance of alcohol consumption. procedure, additional testing may be
Administer antibiotic therapy if ordered. performed to evaluate or monitor
Remind the patient of the importance progression of the disease process
of completing the entire course of and determine the need for a change A
antibiotic therapy, even if signs and in therapy. Evaluate test results in
symptoms disappear before comple relation to the patients symptoms and
tion of therapy. other tests performed.
Reinforce information given by the
patients HCP regarding further testing, RELATED MONOGRAPHS:
treatment, or referral to another HCP. Related tests include albumin, audio
Explain to the patient the importance metry hearing loss, BUN, CBC WBC
of following the medication regimen and differential, creatinine, creatinine
and instructions regarding food and clearance, cultures bacterial (ear, eye,
drug interactions. Answer any ques skin, wound, blood, stool, sputum,
tions or address any concerns voiced urine), otoscopy, potassium, spondee
by the patient or family. speech recognition test, tuning fork
Instruct the patient to be prepared to tests, and UA.
provide the pharmacist with a list of See the Auditory, Genitourinary, and
other medications he or she is already Immune systems tables at the end
taking in the event that the requesting of the book for related tests by
HCP prescribes a medication. body system.

Antipsychotic Drugs and Antimanic Drugs:


Haloperidol, Lithium
SYNONYM/ACRONYM: Antipsychotic drugs: haloperidol (Dozic, Fortunan, Haldol,
Haldol Decanoate, Haloneural, Serenace); antimanic drugs: lithium (Cibalith-S,
Eskalith, Lithane, Lithobid, Lithonate, Lithotabs, PFI-Lith, Phasal).

COMMON USE: To assist in monitoring subtherapuetic, therapeutic, or toxic drug


levels related to medical interventions.

SPECIMEN: Serum (1 mL) collected in a red-top tube.

Drug Route of Administration Recommended Collection Time


Haloperidol Oral Peak: 36 hr
Lithium Oral Trough: at least 12 hr after last dose;
steady state occurs at 90120 hr

NORMAL FINDINGS: (Method: Chromatography for haloperidol; ion-selective elec-


trode for lithium)

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Monograph_A_153-190.indd 161 17/11/14 12:03 PM


A
162

Monograph_A_153-190.indd 162
Volume of Protein
Therapeutic Range Therapeutic Half-Life Distribution Binding
Drug Conventional Units Conversion to SI Units Range SI Units (hr) (L/kg) (%) Excretion
Haloperidol 624 ng/mL SI units = Conventional 1664 nmol/L 1540 1830 90 Hepatic
Units 2.66
Lithium 0.61.2 mEq/L SI units = Conventional 0.61.2 mmol/L 1824 0.71 0 Renal
(chronic) Units 1
Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

17/11/14 12:03 PM
Antipsychotic Drugs and Antimanic Drugs: Haloperidol, Lithium 163

DESCRIPTION: Haloperidol is an anti- erbals, vitamins, and minerals) that


h
psychotic tranquilizer used for can either potentiate or inhibit the
treatment of acute and chronic psy- intended target concentration. Peak
chotic disorders,Tourettes syn- collection times should be docu-
A
drome, and hyperactive children mented carefully in relation to the
with severe behavioral problems. time of medication administration.
Frequent monitoring is important The metabolism of many com-
due to the unstable relationship monly prescribed medications is
between dosage and circulating driven by the cytochrome P450
steady-state concentration. Lithium (CYP450) family of enzymes.
is used in the treatment of manic Genetic variants can alter enzymat-
depression. Daily monitoring of lith- ic activity that results in a spec-
ium levels is important until the trum of effects ranging from the
proper dosage is achieved. Lithium total absence of drug metabolism
is cleared and reabsorbed by the to ultrafast metabolism. Impaired
kidney. Clearance is increased drug metabolism can prevent the
when sodium levels are increased intended therapeutic effect or even
and decreased in conditions associ- lead to serious adverse drug reac-
ated with low sodium levels; there- tions. Poor metabolizers (PM) are
fore, patients receiving lithium at increased risk for drug-induced
therapy should try to maintain a side effects due to accumulation of
balanced daily intake of sodium. drug in the blood, while ultra-rapid
Lithium levels affect other organ metabolizers (UM) require a higher
systems.A high incidence of pulmo- than normal dosage because the
nary complications is associated drug is metabolized over a shorter
with lithium toxicity. Lithium can duration than intended. Other
also affect cardiac conduction, pro- genetic phenotypes used to report
ducing T-wave depressions.These CYP450 results are intermediate
electrocardiographic (ECG) changes metabolizer (IM) and extensive
are usually insignificant and revers- metabolizer (EM). Genetic testing
ible and are seen in 10% to 20% of can be performed on blood sam-
patients on lithium therapy. Chronic ples submitted to a laboratory.The
lithium therapy has been shown to test method commonly used is
result in enlargement of the thyroid polymerase chain reaction.
gland in a small percentage of Counseling and informed written
patients. Other medications indicat- consent are generally required for
ed for use as mood stabilizers genetic testing. CYP2D6 is a gene
include carbamazepine, lamotrigine, in the CYP450 family that metabo-
and valproic acid. Detailed informa- lizes drugs such as antipsychotics
tion is found in the monograph like haloperidol, tricyclic antide-
titled Anticonvulsant Drugs. pressants like nortriptyline, and
Many factors must be consid- beta blockers.Testing for the most
ered in effective dosing and moni- common genetic variants of
toring of therapeutic drugs, includ- CYP2D6 is used to predict altered
ing patient age, patient weight, enzyme activity and anticipate the
interacting medications, electrolyte most effective therapeutic plan.
balance, protein levels, water Incidence of the PM Phenotype is
balance, conditions that affect estimated to be 10% of Caucasians
absorption and excretion, and the and Hispanics, 2% of African
ingestion of substances (e.g., foods, Americans, and 1% of Asians.
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164 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

IMPORTANT NOTE any critically increased or subtherapeu-


These medications are metabolized and tic values and related symptoms.
excreted by the liver and kidneys and It is essential that a critical finding
A are therefore contraindicated in patients be communicated immediately to the
with hepatic or renal disease. Caution is requesting HCP. A listing of these find-
advised for patients with renal impair- ings varies among facilities.
ment. Information regarding medica- Timely notification of a critical find-
tions must be clearly and accurately ing for lab or diagnostic studies is a role
communicated to avoid misunderstand- expectation of the professional nurse.
ing of the dose time in relation to the The notification processes will vary
collection time. Miscommunication among facilities. Upon receipt of the
between the individual administering critical finding the information should
the medication and the individual col- be read back to the caller to verify
lecting the specimen is the most fre- accuracy. Most policies require immedi-
quent cause of subtherapeutic levels, ate notification of the primary HCP,
toxic levels, and misleading information hospitalist, or on-call HCP. Reported
used in calculation of future doses. If information includes the patients
administration of the drug is delayed, name, unique identifiers, critical find-
notify the appropriate department(s) to ing, name of the person giving the
reschedule the blood draw and notify report, and name of the person receiv-
the requesting health-care (HCP) if the ing the report. Documentation of noti-
delay has caused any real or perceived fication should be made in the medical
therapeutic harm. record with the name of the HCP noti-
fied, time and date of notification, and
This procedure is contraindicated any orders received. Any delay in a
for: N/A timely report of a critical finding may
INDICATIONS require completion of a notification
Assist in the diagnosis and form with review by Risk Management.
prevention of toxicity Haloperidol: Greater Than 42 ng/mL
Monitor compliance with (SI: Greater Than 112 nmol/L)
therapeutic regimen Signs and symptoms of haloperidol
toxicity include hypotension, myocar-
POTENTIAL DIAGNOSIS dial depression, respiratory depression,
and extrapyramidal neuromuscular
Level Response reactions. Possible interventions
include emesis (contraindicated in
Normal levels Therapeutic effect
the absence of gag reflex or central
Subtherapeutic Adjust dose as
nervous system depression or excita-
levels indicated
tion) and gastric lavage followed by
Toxic levels Adjust dose as
administration of activated charcoal.
indicated
Haloperidol Hepatic impairment Lithium: Greater Than 2 mEq/L
Lithium Renal impairment (SI: Greater Than 2 mmol/L)
Signs and symptoms of lithium toxicity
CRITICAL FINDINGS include ataxia, coarse tremors, muscle
rigidity, vomiting, diarrhea, confusion,
It is important to note the adverse convulsions, stupor, T-wave flattening,
effects of toxic and subtherapeutic lev- loss of consciousness, and possible
els. Care must be taken to investigate coma. Possible interventions include
signs and symptoms of not enough administration of activated charcoal,
medication and too much medication. gastric lavage, and administration of
Note and immediately report to the HCP intravenous fluids with diuresis.

Monograph_A_153-190.indd 164 17/11/14 12:03 PM


Antipsychotic Drugs and Antimanic Drugs: Haloperidol, Lithium 165

INTERFERING FACTORS Note that there are no food, fluid, or


Blood drawn in serum separator medication restrictions unless by medi
tubes (gel tubes). cal direction.
Haloperidol may increase levels of INTRATEST: A
tricyclic antidepressants and
increase the risk of lithium toxicity. Potential Complications:
Drugs that may increase lithium Lack of consideration for the proper
levels include angiotensin-converting collection time relative to the dosing
enzyme inhibitors, some NSAIDs, schedule can provide misleading infor
and thiazide diuretics. mation that may result in erroneous
interpretation of levels, creating the
Drugs and substances that may potential for a medication-error-related
decrease lithium levels include injury to the patient.
acetazolamide, osmotic diuretics, Avoid the use of equipment containing
theophylline, and caffeine. latex if the patient has a history of
allergic reaction to latex.
Instruct the patient to cooperate fully
and to follow directions. Direct the
NURSING IMPLICATIONS patient to breathe normally and to
AND PROCEDURE avoid unnecessary movement.
Observe standard precautions, and
PRETEST: follow the general guidelines in
Positively identify the patient using at Appendix A. Consider recommended
least two unique identifiers before collection time in relation to the dosing
providing care, treatment, or services. schedule. Positively identify the
Patient Teaching: Inform the patient this patient, and label the appropriate
test can assist in monitoring subthera specimen container with the corre
peutic, therapeutic, or toxic drug levels. sponding patient demographics,
Obtain a history of the patients com initials of the person collecting the
plaints, including a list of known aller specimen, date, and time of collection,
gens, especially allergies or sensitivities noting the last dose of medication
to latex. taken. Perform a venipuncture.
These medications are metabolized Remove the needle and apply direct
and excreted by the kidneys and liver. pressure with dry gauze to stop bleed
Obtain a history of the patients genito ing. Observe/assess venipuncture site
urinary and hepatobiliary systems, for bleeding or hematoma formation and
symptoms, and results of previously secure gauze with adhesive bandage.
performed laboratory tests and diag Promptly transport the specimen to
nostic and surgical procedures. the laboratory for processing and
Obtain a list of the patients current analysis.
medications, including herbs, nutri
tional supplements, and nutraceuticals POST-TEST:
(see Appendix H online at DavisPlus). Inform the patient that a report of the
Note the last time and dose of medica results will be made available to the
tion taken. requesting HCP, who will discuss the
Review the procedure with the patient. results with the patient.
Inform the patient that specimen collec Nutritional Considerations: Include avoid
tion takes approximately 5 to 10 min. ance of alcohol consumption.
Address concerns about pain and Reinforce information given by the
explain that there may be some discom patients HCP regarding further testing,
fort during the venipuncture. treatment, or referral to another HCP.
Sensitivity to social and cultural issues,as Explain to the patient the importance
well as concern for modesty, is important of following the medication regimen
in providing psychological support and instructions regarding drug
before, during, and after the procedure. interactions.

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166 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

Instruct the patient receiving haloperi Depending on the results of this


dol to immediately report any unusual procedure, additional testing may be
symptoms (e.g., arrhythmias, blurred performed to evaluate or monitor
vision, dry eyes, repetitive uncontrolled progression of the disease process
A movements) to his or her HCP. Instruct and determine the need for a change
the patient receiving lithium to in therapy. Evaluate test results in
immediately report any unusual relation to the patients symptoms
symptoms (e.g., anorexia, nausea, and other tests performed.
vomiting, diarrhea, dizziness, drowsi
ness, dysarthria, tremor, muscle
twitching, visual disturbances) to his RELATED MONOGRAPHS:
or her HCP. Answer any questions or Related laboratory tests include
address any concerns voiced by the albumin, BUN, calcium, creatinine,
patient or family. ECG, glucose, magnesium, osmolality
Instruct the patient to be prepared to urine, potassium, sodium, T4, and TSH.
provide the pharmacist with a list of See the Genitourinary and
other medications he or she is already Hepatobiliary systems tables at the
taking in the event that the requesting end of the book for related tests by
HCP prescribes a medication. body system.

Antithrombin III
SYNONYM/ACRONYM: Heparin cofactor assay, ATIII.

COMMON USE: To assist in diagnosing heparin resistance or disorders resulting


from a hypercoagulable state such as thrombus.

SPECIMEN: Plasma (1 mL) collected in a completely filled blue-top (3.2% sodium


citrate) tube. If the patients hematocrit exceeds 55%, the volume of citrate in the
collection tube must be adjusted.

NORMAL FINDINGS: (Method: Chromogenic Immunoturbidimetric)

This procedure is contraindicated


Conventional Units for: N/A
Age (% of Normal)
14 days 3987% POTENTIAL DIAGNOSIS
529 days 4193%
13 mo 48108%
Increased in
36 mo 73121%
Acute hepatitis
612 mo 84124%
Renal transplantation (Some stud-
15 yr 82139%
ies have demonstrated high lev-
617 yr 90131%
els of AT III in proximal tubule
18 yr-older 80120%
epithelial cells at the time of
adult
renal transplant. The exact rela-
tionship between the kidneys and

Monograph_A_153-190.indd 166 17/11/14 12:03 PM


`1-Antitrypsin and `1-Antitrypsin Phenotyping 167

AT III levels is unknown. Congenital deficiency


It is believed the kidneys may Disseminated intravascular coagulation
play a role in maintaining (related to increased consumption)
plasma levels of AT III as evi- Liver transplantation or partial hep- A
denced by the correlation atectomy (related to decreased
between renal disease and low synthesis)
AT III levels.) Nephrotic syndrome (related to
Vitamin K deficiency (decreased increased protein loss)
consumption related to impaired Pulmonary embolism (related to
coagulation factor function) increased consumption)
Septic shock (related to increased
Decreased in
consumption and decreased syn-
Carcinoma (related to decreased
thesis due to hepatic impairment)
synthesis)
Chronic liver failure (related to Venous thrombosis (related to
increased consumption)
decreased synthesis)
Cirrhosis (related to decreased
synthesis) CRITICAL FINDINGS: N/A
Find and print out the full monograph at DavisPlus (http://davisplus.fadavis
.com, keyword Van Leeuwen).

`1-Antitrypsin and `1-Antitrypsin


Phenotyping
SYNONYM/ACRONYM: a1-antitrypsin: A1AT, a1-AT, AAT; a1-antitrypsin phenotyp-
ing: A1AT phenotype, a1-AT phenotype, AAT phenotype, Pi phenotype.

COMMON USE: To assist in the identification of chronic obstructive pulmonary dis-


ease (COPD) and liver disease associated with a1-antitrypsin (a1-AT) deficiency.

SPECIMEN: Serum (1 mL) for a1-AT and serum (2 mL) for a1-AT phenotyping
collected in a gold-, red-, or red/gray-top tube. Whole blood from one full laven-
der-top (EDTA) is also acceptable.

NORMAL FINDINGS: (Method: Rate nephelometry for a1-AT, isoelectric focusing/


high-resolution electrophoresis for a1-AT phenotyping)

`1-Antitrypsin

Age Conventional Units SI Units (Conventional Units 0.01)


01 mo 124348 mg/dL 1.243.48 g/L
26 mo 111297 mg/dL 1.112.97 g/L
7 mo2 yr 95251 mg/dL 0.952.51 g/L
319 yr 110279 mg/dL 1.12.79 g/L
Adult 126226 mg/dL 1.262.26 g/L

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Monograph_A_153-190.indd 167 17/11/14 12:03 PM


168 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

`1-Antitrypsin Phenotyping Postoperative recovery (related


There are three major protease inhibi- to rapid, nonspecific response
tor phenotypes: to inflammation or stress)
A MMNormal Pregnancy (related to rapid,
nonspecific response to stress)
SSIntermediate; heterozygous
Steroid therapy
ZZMarkedly abnormal;
Stress (extreme physical) (related
homozygous
to rapid, nonspecific response to
The total level of measurable a1-AT stress)
varies with genotype. The effects of
Decreased in
a1-AT deficiency depend on the
COPD (related to malnutrition
patients personal habits but are most
and evidenced by decreased
severe in patients who smoke tobacco.
protein synthesis)
This procedure is Homozygous 1-ATdeficient
contraindicated for: N/A patients (related to decreased
protein synthesis)
POTENTIAL DIAGNOSIS Liver disease (severe) (related to
decreased protein synthesis)
Increased in Liver cirrhosis (infant or child) (relat-
Acute and chronic inflammatory ed to decreased protein synthesis)
conditions (related to rapid, Malnutrition (related to
onspecific response to
n insufficient protein intake)
inflammation) Nephrotic syndrome (related to
Carcinomas (related to rapid, increased protein loss from
nonspecific response to diminished renal function)
inflammation)
Estrogen therapy CRITICAL FINDINGS: N/A
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Apolipoproteins: A, B, and E
SYNONYM/ACRONYM: Apo A (Apo A1), Apo B (Apo B100), and Apo E.

COMMON USE: To identify levels of circulating lipoprotein to evaluate the risk of


coronary artery disease.

SPECIMEN: Serum (1 mL) collected in a gold-, red-, or red/gray-top tube or


plasma collected in a green- (heparin) or lavender-top (EDTA) tube for Apo A
and Apo B; Plasma (1 mL) collected in a lavender-top (EDTA) tube.

NORMAL FINDINGS: (Method: Immunonephelometry for Apo A and Apo B; PCR with
restriction length enzyme digestion and polyacrylamide gel electrophoresis for
Apo E)

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Apolipoproteins: A, B, and E 169

Apolipoprotein A

Age Conventional Units SI Units (Conventional Units 0.01)


Newborn
A
Male 4193 mg/dL 0.410.93 g/L
Female 38106 mg/dL 0.381.06 g/L
6 mo4 yr
Male 67163 mg/dL 0.671.63 g/L
Female 60148 mg/dL 0.61.48 g/L
Adult
Male 81166 mg/dL 0.811.66 g/L
Female 80214 mg/dL 0.802.14 g/L

Apolipoprotein B

Age Conventional Units SI Units (Conventional Units 0.01)


Newborn5 yr 1131 mg/dL 0.110.31 g/L
517 yr
Male 47139 mg/dL 0.471.39 g/L
Female 4196 mg/dL 0.410.96 g/L
Adult
Male 46174 mg/dL 0.461.74 g/L
Female 46142 mg/dL 0.461.42 g/L

Normal Apo E: Homozygous phenotype for e3/e3.

DESCRIPTION:Apolipoproteins that Apo A measurements may be


assist in the regulation of lipid more important than HDL cho-
metabolism by activating and lesterol measurements as a pre-
inhibiting enzymes required for dictor of coronary artery disease
this process. The apolipoproteins (CAD). There is an inverse rela-
also help keep lipids in solution tionship between Apo A levels
as they circulate in the blood and risk for developing CAD.
and direct the lipids toward the Because of difficulties with meth-
correct target organs and tissues od standardization, the above-listed
in the body. A number of types reference ranges should be used
of apolipoproteins have been as a rough guide in assessing
identified (A, B, C, D, E, H, J), abnormal conditions. Values for
each of which contain sub- African Americans are 5 to
groups. Apolipoprotein A (Apo A), 10 mg/dL higher than values for
the major component of high- whites. Apolipoprotein B (Apo B),
density lipoprotein (HDL), is syn- the major component of the
thesized in the liver and intes- low-density lipoproteins (chylo-
tines. Apo A-I activates the microns, low-density lipoprotein
enzyme lecithin-cholesterol acyl- [LDL], and very-low-density
transferase (LCAT), whereas Apo lipoprotein), is synthesized
A-II inhibits LCAT. It is believed in the liver and intestines.

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170 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

POTENTIAL DIAGNOSIS
Apolipoprotein E is found in Apolipoproteins are the protein por-
most lipoproteins, except LDL, tion of lipoproteins. Their function is
and is synthesized in a variety of
A cell types including liver, brain
to transport and to assist in cell sur-
face receptor recognition and cellu-
astrocytes, spleen, lungs, adre- lar absorption of lipoproteins to be
nals, ovaries, kidneys, muscle used as energy. While studies of the
cells, and in macrophages. The exact role of apolipoproteins in
largest amount is produced by health and disease continue, there
the liver; the next significant is a very strong association between
amount is produced by the brain. Apo A and HDL good cholesterol
There are three forms of Apo E: and Apo B and LDL bad cholesterol.
apo-E 2, apo-E 3, and apo-E 4, and
six possible combinations; of Apolipoprotein A
these, Apo-E 3 (e3/3e) is the fully
functioning form. The varied Increased in
roles of Apo E include removal Familial hyper--lipoproteinemia
of chylomicrons and very-low- Pregnancy
density lipoprotein (VLDL) from Weight reduction
the circulation by binding to Decreased in
LDL. The Apo E2 isoform demon- Abetalipoproteinemia
strates significantly less LDL Cholestasis
receptor binding, which results Chronic renal failure
in impaired clearance of chylo- Coronary artery disease
microns, VLDL, and triglyceride Diabetes (uncontrolled)
remnants. The presence of Apo E Diet high in carbohydrates or poly-
isoforms E2 and E4 is associated unsaturated fats
with high cholesterol levels, high Familial deficiencies of related
triglyceride levels, and the pre- enzymes and lipoproteins (e.g.,
mature development of athero- Tangiers disease)
sclerosis. The presence of the E2 Hemodialysis
isoform is associated with type Hepatocellular disorders
III hyperlipidemia, a familial dys- Hypertriglyceridemia
lipidemia, which is important to Nephrotic syndrome
distinguish from other causes of Premature coronary heart disease
hyperlipidemia to determine the Smoking
correct treatment regimen. Apo
E4 is being used in association Apolipoprotein B
with studies of predisposing fac-
tors in the development of Increased in
Alzheimers disease. Detailed Anorexia nervosa
information is found in the study Biliary obstruction
titled Alzheimers Disease Coronary artery disease
Markers. Cushings syndrome
Diabetes
Dysglobulinemia
This procedure is Emotional stress
contraindicated for: N/A Hemodialysis
Hepatic disease
INDICATIONS Hepatic obstruction
Evaluation for risk of CAD Hyperlipoproteinemias

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Apolipoproteins: A, B, and E 171

Hypothyroidism Drugs that may decrease Apo E


Infantile hypercalcemia levels include bezafibrate, fluvas-
Nephrotic syndrome tatin, gemfibrozil, ketanserin,
Porphyria lovastatin, niacin, nifedipine, oral A
Pregnancy contraceptives, pravastatin,
Premature CAD probucol, and simvastatin.
Renal failure Failure to follow dietary restrictions
Werners syndrome before the procedure may cause
the procedure to be canceled or
Decreased in
repeated.
Acute stress (burns, illness)
Chronic anemias
Chronic pulmonary disease
Familial deficiencies of related NURSING IMPLICATIONS
enzymes and lipoproteins (e.g., AND PROCEDURE
Tangiers disease) PRETEST:
Hyperthyroidism
Positively identify the patient using at
Inflammatory joint disease
least two unique identifiers before
Intestinal malabsorption providing care, treatment, or services.
-Lipoprotein deficiency (Tangiers Patient Teaching: Inform the patient this
disease) test can assist in assessing and moni
Malnutrition toring risk for coronary artery (heart)
Myeloma disease.
Reyes syndrome Obtain a history of the patients com
Weight reduction plaints, including a list of known aller
gens, especially allergies or sensitivities
CRITICAL FINDINGS: N/A to latex.
Obtain a history of the patients cardio
vascular system, symptoms, and
INTERFERING FACTORS results of previously performed labora
Drugs and substances that may tory tests and diagnostic and surgical
increase Apo A levels include anti- procedures.
convulsants, beclobrate, bezafibrate, Obtain a list of the patients current
ciprofibrate, estrogens, furosemide, medication, including herbs, nutritional
lovastatin, pravastatin, prednisolone, supplements, and nutraceuticals (see
simvastatin, and ethanol (abuse). Appendix H online at DavisPlus).
Drugs that may decrease Apo A Review the procedure with the patient.
levels include androgens, Inform the patient that specimen
collection takes approximately 5 to
-blockers, diuretics, and probucol. 10 min. Address concerns about
Drugs that may increase Apo B lev- pain and explain that there may
els include amiodarone, androgens, be some discomfort during the
-blockers, catecholamines, cyclo- venipuncture.
sporine, diuretics, ethanol (abuse), Sensitivity to social and cultural issues,
etretinate, glucogenic corticoste- as well as concern for modesty, is
roids, oral contraceptives, and important in providing psychological
phenobarbital. support before, during, and after the
Drugs that may decrease Apo B procedure.
Instruct the patient to abstain from
levels include beclobrate, captopril, food for 6 to 12 hr before specimen
cholestyramine, fibrates, ketanserin, collection.
lovastatin, niacin, nifedipine, pravas- Note that there are no fluid or medica
tatin, prazosin, probucol, and tion restrictions unless by medical
simvastatin. direction.

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172 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications

INTRATEST: decrease sodium intake, achieve a


normal weight, ensure regular partici
Potential Complications: N/A
pation of moderate aerobic physical
Ensure that the patient has complied activity three to four times per week,
A with dietary or activity restrictions, and eliminate tobacco use, and adhere
pretesting preparations; assure that to a heart-healthy diet. If triglycerides
food has been restricted for at least also are elevated, the patient should
6 to 12 hr prior to the procedure. be advised to eliminate or reduce
Avoid the use of equipment containing alcohol. The 2013 Guideline on
latex if the patient has a history of Lifestyle Management to Reduce
allergic reaction to latex. Cardiovascular Risk published by
Instruct the patient to cooperate fully the ACC and AHA in conjunction
and to follow directions. Direct the with the NHLBI recommends a
patient to breathe normally and to Mediterranean-style diet rather
avoid unnecessary movement. than a low-fat diet. The new guideline
Observe standa